Medical Home

Dr. Glenn Steele, the president and CEO of Geisinger Health System, recently co-authored an article in Health Affairs and appeared at a Health Affairs forum here in DC to talk about the innovations at Geisinger, and the ways that Geisinger's unique characteristics might limit their adaptability elsewhere. Geisinger is both a health plan and a health network spanning 41 counties in Pennsylvania, and it has an unusual mix of Geisinger and non-Geisinger physicians, of open-and closed-staff facilities. It is blazing trails on many fronts, in chronic and acute care, from medical homes to its ProvenCare initiative for certain acute inpatient conditions and procedures.

We spoke with Dr. Steele recently and turned his question around. We weren't so much interested in the limits of Geisinger's example; we wanted to know what would work elsewhere—which of those trails could be followed or adapted by others. To our relief, Dr. Steele told us that other hospitals and policy experts have been flocking to Pennsylvania recently trying to answer that precise question. And the answer is that quite a bit of it would work elsewhere.

We've mentioned Community Care, North Carolina's innovative Medicaid program for chronic disease management, briefly in the past but today's News and Observer takes a detailed look. Community Care has been shown to save money —and improve the quality of care for Medicaid patients with conditions such as diabetes and asthma. The savings are impressive—$100 million a year, or $2 for every $1 the state spent on the program, which covers 810,000 Medicaid patients in "medical homes" through 14 nonprofit networks around the state.

The patients are monitored closely, so that conditions are kept in check and complications and hospitalizations are minimized. Case managers work with physicians and other providers, hospitals, public health and social service agencies to coordinate comprehensive care and make sure that patients don't fall through the cracks and that transitions—say after a hospital admission—are handled smoothly. Doctors get paid a fee to compensate them for the time-consuming aspects of care coordination and management that are often go not reimbursed.

While our colleague Paul Testa was going through the latest numbers on the incredibly shrinking primary care work force, we were over at the Health Affairs session listening to Robert Berenson of the Urban Institute talk about how to build the Medical Home, which is in some ways a souped up 21st century version of primary care.

Bob (who has guest blogged for us in the past) said a lot of docs don't like primary care in our current world because of what he called the hamster syndrome. They feel like they are hamsters spinning on wheels in a cage, unable to keep up, unable to move ahead. The medical home is supposed to restore primary care's rightful place in the healthcare universe, while as Berenson wrote in the current issue of Health Affairs, "providing a source of confidence, advocacy, and coordination for patients as they encounter the disconnected parts and often daunting complexity of the health care system." Advocates of medical homes stress their importance in managing chronic diseases. Naturally, to make them work, we're going to have to pay primary care providers better and differently if we want care coordination and oversight to replace piecemeal, pay-for-procedure medicine.

Crime doesn’t pay. Unfortunately, neither does primary care—or at least not enough, especially when you’re carrying an average of $139,000 in debt into your residency.

Two new studies published today in JAMA continue to sound the alarm bell about the future of our physician workforce. One, a survey of nearly 1,200 fourth year medical students, found that only 2 percent planned to go into general internal medicine. More than 23 percent planned a career in internal medicine—a field generally associated with primary care but which also contains more lucrative subspecialties.

The primary reasons pushing these doctors away from primary care: income and lifestyle. Close to 65 percent believed they would earn less income going into internal medicine, 68 percent believed they would have to deal with more paperwork and 42 percent were turned off by the need to bring work home with them as an internist. (See our colleague Joanne Kenen's post today about medical homes, primary care and the hamster wheel.)