Dream or Reality?

Consider that in the U.S.…

• Only 1/3 of patients released from the hospital are followed up within 60 days;
• A family of four pays on average over $19,000 per year for healthcare costs which have doubled in less than 9 years;
• 75 percent of consumers say the recent economic slowdown has impacted their healthcare spending;
• The number of people who are underinsured has grown 60 percent to 25 million over the past four years;
• Many individuals are paying such high premiums for ‘catastrophic care’ that they cannot afford care due to high deductibles. So what are they really paying for?
• 63 percent report that monthly healthcare expenses limit their ability to purchase other essentials such as housing, groceries, gas, and education;
• 25 percent report skipping seeing a physician when they were sick or injured;
• Many people with chronic illnesses delay seeking treatment, ending up in the emergency room or being admitted to the hospital with annual costs to treat estimated at $600 billion;
• 38 percent of consumers rate the healthcare system as ‘failing’;
• Healthcare expenditures in the U.S. exceed $2 trillion a year. (In comparison, the federal budget is $3 trillion a year);
• The amount people pay for health insurance increased 30 percent from 2001-2005 while income for the same period increased 3 percent (before the economic turndown). PricewaterhouseCoopers estimates an insurance increase of 9 percent for 2011;
• Though primary care presently requires more overhead and more support services, fee for service does not adequately cover evaluation and management services.

Can’t we do better?

James E. Bailey, MD, who is professor of medicine in the Division of General Internal Medicine at University of Tennessee Health Science Center, director of Healthy Memphis Data Center and an advocate of the patient-centered medical home (PCMH), believes we can. But it will require a sea change.

Picture, if you can, “a practice model with expanded access to urgent care to avoid emergency room visits or hospital admissions so that patients receive the care they need, when they need it, at the right place, at the right time, every time,” said Bailey “That is what is needed.”

Sound too good to be true? Possibly, but the proof is in.

The PCMH may still exist as a dream for most U.S. practices but the good news is that seven national demonstration projects located at Community Care of North Carolina; Group Care Cooperative of Puget Sound; Health Partners Medical Group Bestcare, PCMH; Genesee Healthplan Healthworks, PCMH; John Hopkins Guided Care; Geisinger Health System ProvenCare Navigator; Intermountain Healthcare Medical Group, PCMH, have shown conclusively that when good, basic, comprehensive primary care systems are implemented, hospitalizations go down, emergency room use is reduced, costs decrease, and patient satisfaction goes up, according to Bailey. Surveys also show that the PCMH model reduces physician burn-out and improves quality of life for both patients and physicians.

The model

The patient-centered medical home model is characterized by a medical practice with personal physicians trained to provide ongoing, continuous and comprehensive care to patients and to direct the provision of all of their healthcare needs using a holistic approach. The physician leads a team dedicated to making sure each patient gets recommended care using a proactive approach emphasizing prevention rather than a reactive approach that emphasizes emergency care for acute illness. As a result, patients get enhanced access to the physician and team members.

Patients are tracked using electronic records to make sure they get the regular support services needed most with chronic illnesses such as diabetes, heart disease, asthma, and COPD. Involving patients in the decision-making and providing coordinated care are essential characteristics.

The model reduces the fragmentation of care and inappropriate or overuse of specialists and the ER, avoiding crises and thereby reducing hospital admissions.

“There are well laid out national models for what capacities are most important and critical to this model and there are also nationally vetted payment models that are pretty well established. But the one clear message that has come out is that physicians would like to see health plans considering the PCMH to adopt uniform payment approaches,” said Bailey.

National models of blended comprehensive care payment for PCMH services include three main components:

• The traditional fee for service – paid when the patient is seen;
• A care coordination fee – a monthly fee per person, based on the number of patients with chronic illnesses; and
• Pay for performance – based on the percent of patients receiving recommended care and sometimes the percent with high satisfaction.

“Primary care physicians are interested in this model. We can practice better medicine and receive higher reimbursement,” said Bailey. “The most cost-effective approach would be for primary care physicians to work through an ACO (Accountable Care Organization), a physician/hospital organization, to help hospitals decrease unnecessary hospitalizations and emergency care by contracting to improve access to high quality outpatient care.”

Testing the water

Only a few practices in the Greater Memphis area are currently getting a blended medical home payment. But many practices are beginning to incorporate aspects of the medical home model on a limited basis, added Bailey. These would include coordination of care, registries to track outreach patients to ensure that they receive recommended care and adoption of a certified EHR system. The PCMH requires certain capacities to receive NCQA certification.

 “All the organized practices see this coming down the road. Frankly, it is the type of practice they’ve been wanting for years because it‘s about delivering a much better product to patients and helping them get the preventive care they need most so that they don’t need hospital services,” claims Bailey. “Though physicians are very interested in the patient-centered medical home, it does mean changing the way they do things.

“It’s a difficult transition and needs lots of infrastructure,” he continued. “UT Medical Group is working to build that infrastructure.  Our Germantown and Harbor of Health practices are the only NCQA-recognized PCMH programs in West Tenn.   The Medplex where I practice is also working to build PCMH infrastructure; we plan to have an EHR system within this fiscal year.”

U.S. lags behind in adopting medical home concept

The U.S. trails the developed world in adopting and implementing the medical home concept. We have the most expensive but, frequently, inefficient care in the world. An example - home visits are almost unheard of in this country but a common practice in many European countries because it has been shown to save costs and improve care. Some countries have capitalized on the medical home’s quality care, efficiencies and lower costs for years.

Challenges?

“It’s all about the money,” said Bailey. “I think the most import thing is to change the way we pay – if we really want to support the medical home concept, we need to start paying for it. That will drive it. We need to be working on employers and insurers to pay for PCMH services and to support practice efforts to gain NCQA accreditation,” Bailey advised. Potential opportunities Bailey mentioned to support primary care include:

• Comprehensive care (medical home) payment using an industry standard approach;
• Multi-plan funded care coordination nurses;
• Preventable hospitalization and ED use feedback reports from MidSouth eHealth Alliance;
• Peer to peer ‘Rapid Cycle Improvement’ learning collaborative;
• Direct practice coaching in developing medical home capacity (i.e. NCQA accreditation);
• Sharing best practices educational events;
• Adoption and distribution of chronic disease patient self-management tools.

Care coordinator nurse is key

“The care coordinator nurse (or practice-based care coordinator) is an additional component required in most medical home practices to help not only with the transition of care for recently hospitalized patients but also be dedicated to the new tasks related to monitoring patients and their follow up care. I think every practice needs this if they want to be a PCMH,” added Bailey.

Practices already have nurses who handle refill requests, urgent appointments, assisting home health orders, writing orders for diabetic supplies, etc. “But it’s like the chicken and the egg scenario,” Bailey reasoned. “In order for physicians to invest in the reorganization of their practice and how they handle patient care, they need to be paid differently so they can incorporate the infrastructure needed. What has to happen simultaneously with the new payment model is for the docs to invest in electronic health records and to invest in an outreach nurse that helps reach patients who need recommended care.

“Without the infrastructure in place, it is difficult for physicians to make the transition, he continued. “And without the system in place, they cannot be reimbursed through the certified medical home comprehensive payment system.”

Where is Shelby County in the scheme of things?

Shelby County is rich with resources and there are numerous initiatives and incentives for moving the comprehensive care medical home model trend forward. Hospital non-reimbursement for CHF readmissions is a major incentive for payment change. And the federal stimulus for EHR is also serving as a powerful impetus for practices.

Other initiatives

Progress has been steady for adopting electronic records. TNrec/QSource’s most recent recruitment figures for implementing certified EHR systems in medical practices include: 553 in West Tenn., 293 in Middle Tenn., and 485 in East Tenn. for a total of 1,331. Also, all major hospitals and many of the large clinics are participating in the MidSouth eHealth Alliance (MSeHA) to access its electronic exchange of health information.

Healthy Memphis Common Table, and the Memphis and Bluff City Medical Societies have joined forces to form a regional collaborative to improve ambulatory care through “Project Better Care.” According to ER physician Bill Falvey, MD, “It’s a partnership… to address the challenges many primary care doctors face in effectively managing patients with chronic illness who are frequent users of the ER. We’re targeting patients with type 2 diabetes initially,” since they often end up in the ER. Goals are to educate patients about their disease, learning to care for themselves and following recommendations for care.

Insurance companies are listening. BCBS is evolving toward being more patient-centered in their delivery system. According to Thomas Lundquist, MD, VP, Performance Measurement & Improvement of BlueCross BlueShield of Tennessee, as of June, 2011, BCBS has 23 active medical home practices across the state with an additional 12 in process. These practices encompass more than 60 sites and 400 physicians statewide. Approximately 40,000 members are eligible for the medical home; 20,000 have enrolled and the other half is expected to enroll.

“These members have one or more of six chronic disease conditions: diabetes, asthma, COPD, hypertension, hyperlipidemia and CHF. In terms of the Memphis/Shelby County market, we have seven medical home sites in Memphis, some with multiple practice sites, and expect to have more than 10 sites before the end of 2011 in this region,” added Lundquist.

“BlueCross BlueShield has moved from piloting the medical home in 2009-early 2010 to making the PCMH a full blown programmatic effort. We really believe that primary care needs the partnership (of insurers) to help with the focus on changing their practices to become forward thinking - prospectively reaching out to the patients with chronic diseases. Also building the infrastructure necessary to care for the patients; this is critical to the system. Healthcare delivery is really transforming itself for the future.”

Their experience thus far with the medical home has brought positive review from members, claimed Lundquist. “We are getting some great stories from patients who feel this is really making a difference in their lives.”

PCMH – it’s happening locally

Bailey has no doubt that the PCMH is going to happen in Shelby County. “I think it’s happening, though more slowly than I’d like. There will undoubtedly be pushback because a lot of people have an interest in the status quo. But ultimately, we know the way to reduce cost and improve quality – it is only a question of will,” he said.

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