Testing a new way to provide health care
Tuesday, October 13th, 2009
By: Taunya English
tenglish@whyy.org
On TV, Cheers was the kind of bar where everybody knew your name. Some people think a doctor’s office should be the same kind of place, and Pennsylvania is trying out that idea with a new model of primary care called “the medical home.” Some doctors are getting bonuses to test whether an in-touch, high-tech approach can improve health and cut costs.
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Patients from Greenhouse Internists stretch before heading out for the Tuesday walk lead by health educator Emily Desnouee.
Givens: My Name is Debi Givens and I live right down there on Mt. Airy Avenue.
Givens has diabetes, arthritis; and after two knee replacements, she sometimes uses a cane. Her doctor suggested the walking group.
Health educator Emily Desnouee checks Debi Givens' form during stretches outside Greenhouse Internists in Mt. Airy, Philadephia.
Givens: She wrote it on a piece of paper, and told me to call. She didn't ask me anything, she just told me to do it. We have that kind of relationship, she tells me to do something, most times I do it.
Greenhouse is one of those medical homes. The practice was redesigned to give people more support to manage their health.
Dr. Jeffrey Brenner tried the medical home model in Camden. He says the switch usually begins with digital records to better track patients.
Brenner: So in a new model of care, a doctor would walk into their office on Monday morning, press a button and out would print a report of all of their diabetic patients who hadn't refilled their prescriptions; their asthmatic patients who'd been to the emergency room too often. And they would sit with a team of other people and plan out what they are going to do for those patients.
Doctors at Greenhouse Internists in Mt. Airy have redesigned the practice to give patients more support in managing their health.
Greenhouse patient Allen Hinkey got one of those messages.
Hinkey: I was supposed to call in my blood pressure every week or so, and of course I always forgot.
Hinkey's wife Ena Rosen.
Rosen: I new that this is something that he needed to be doing, and when I raised this with my husband, it was a little bit of a sensitive issue, I was perceived to sort of be nagging.
When the doctor's office called, Hinkey was more receptive.
Hinkey: Well, it was different in that here's a doctor and he's taking the time out of his practice to review his patient's records and then following up with a reminder to send in the readings.
Primary care doctors say the team approach provides better care, but most health plans only pay for the doctor's time during face-to-face visits. Jeffrey Brenner:
Dr. Richard Baron converted his Mt. Airy practice to a patient-centered medical home by adding staff and new technology.
That’s changing. Pennsylvania and the state's largest health insurance companies have begun rewarding doctors who switch to the medical home model. Physicians in the pilot program get a lump-sum bonus. It can be as much as an extra $85,000. That pays for the new technology and the extra staff it takes to re-design a practice.
Baron: Many of us believe that this will decrease total costs of health care.
Mt. Airy physician Richard Baron …
Baron: Lots of health care leaders have spoken about that, that trying to strengthen primary care is part of the national health care agenda.
Baron says he’s seeing better results for his patients with diabetes, hypertension and high cholesterol. But that might not be enough.
Baron: One of the biggest questions is: Do patients who receive care in primary care offices that are set up this way, ultimately cost the insurance companies less?
Health educator Emily Desnouee
Brenner: If you help a diabetic become better controlled, it could take a long time before you see the financial benefits of that at the insurance company level.
Medical home pilot projects are under way across the country. Early reports show steady health gains, but it may take years to know if the model saves enough money to justify the extra cost.
Tom, I think the key to the success of the medical home is the Case Manager, a nurse who has training in care coordination and can take the time to access a patient to determine barriers to adherence. The case manager has the expertise to talk to the patient gain their trust and help them become an active participant in the plan of care. The case manager also will raise issues that the physician/patient can address and document the process so that outcomes are reported and the model can be evaluated. With the proper documentation system, the case manager should be able to show the history of the patient's course of care before the care coordination model was started and with interventions how that course of care has improved. Physicians and nurse case managers can make good partners and I am excited to see these types of
program become more widespread.
Anne Llewellyn, RN-BC, MS, BHSA, CCM, CRRN
This approach WILL work but proving it will be difficult. I ran numerous health plans and also was the medical director for a large disease management company. As with the disease management programs typically run by vendors or insurers, the analysis is difficult and expensive.
How do you prove a negative, i.e. an admission that did not occur. You can do pre/post in a given time period for a population but the analysis then needs to include other non hospital based costs that are certain to go up such as diabetes classes, extra visits to the office for acute issues,increased costs for medications if the patient is now compliant, etc. Physicians are not typically set up to perform these analytical studies and MCOs would need to have a huge percentage of a given practice to obtain a significant sample size for the analysis.
I just hope that the practices are rewarded early on as the costs are long term to a practice and current reimbursement methodology does not reward the programs individual physicians will develop.