Medical Homes

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 have said before that we cannot control health care costs until we begin to pay doctors in a way that makes sense. The good news is that the Patient Centered Primary Care Collaborative (PCPCC) is on the case, and its many members are leading the charge.

On Friday, I joined the PCPCC for its summit on medical homes and participated in a panel about how the medical home concept fits in to health policy and the reform conversation. I was joined on the panel by Katherine Hayes (former staffer for Senators John Chafee and Evan Bayh) and Mayra Alvarez (staffer for Senator Dick Durbin).

There were two central and common themes:

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.

We came to the National Press Club today ready for a debate on health care and entitlement reform. What we got was a lot of consensus on the serious challenge of health care cost growth and the need to do everything in our power to bend the cost curve. That, and an interesting bowl of gazpacho with chunks of watermelon in it….

Our cold soup confusion aside, we were pleased to participate in the panel of experts put together by our colleague Maya MacGuineas, Director of New America’s Fiscal Policy Program and President, Committee for a Responsible Federal Budget.

Our co-panelists addressed the need to make hard choices in health care and the budget and the potential of Medicare to drive changes in the system. With such a broad range of expertise in fiscal and health policy, there was naturally some disagreement on priorities and political viability of different options. But every panelist shared the goal of getting health care costs under control. The purpose of our presentation was to show that there are real, tangible ways of holding down costs that can provide the basis of meaningful reform.

 You can find the whole discussion webcast here. Below are a few of our key themes:

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.)

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.

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.

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:

"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 post. They are not necessarily mutually exclusive, but they aren't synonymous.)

* * *