After returning from a Nevada hiking trip in June, Catherine Helling, 45, of Dubuque, Iowa, landed in the hospital for cellulitis, a dangerous skin infection. Early into Helling's six-day stay, her internist visited, coordinated Helling's hospital and follow-up care and made sure the mother of three got circulation stockings, vital to getting Helling back on her feet quickly. "People are amazed my doctor would do that," says Helling, who was back to work after a week.
Helling's doctor, Christine Sinsky, requires no special fee for the extra service. Same- or next-day appointments by doctors who coordinate patient care are just the tip of the iceberg at Sinsky's multi-specialty medical group practice, Dubuque's Medical Associates Clinic. The clinic's acute care center has extended hours, open daily from 7 a.m. to 9 p.m. Clinic patients email their doctors, get their medical records via the practice's secure website, are encouraged to share their thoughts and concerns about possible treatments with doctors, and receive a next-step care plan after each visit. But Helling says what's "truly amazing" was what happened when she was diagnosed with diabetes nearly two years ago. After prescribing medicine, Sinsky asked how she could support Helling in getting her blood sugar and weight under control. When Helling said unreliable scales frustrated past efforts, Sinsky arranged for her patient to come in once a week for free to get weighed on clinic scales. That support was vital: "I've been able to lose over 150 pounds in the last 18 months," says Helling, who is no longer diabetic.
Is this level of care a relic of a bygone era? No. Sinsky is on the leading edge of an innovation shaking up the practice of medicine: the patient-centered medical home (PCMH). Think of the idealized patience, caring and individualized attention that actor Robert Young showed his patients on TV's "Marcus Welby, M.D." Combine that with a modern approach where patients are supported by a team—including doctors, nurses, health coaches, pharmacists, social workers and others—interested in taking care of all their patients, not just those who arrive sick, and engage patients with 21st century information technology tools, such as email, text, Web 2.0 tools and electronic medical records. That's what a medical home is like – and private practices, hospitals, health plans, Medicare and states are embracing and financing them.
"Part of what's happening in a medical home is moving from being reactive to being more proactive, and making sure patients' care is coordinated and followed," says Robert Reid, a physician and senior investigator at Group Health Research Institute. Reid studied the effects of a PCMH pilot at Group Health Cooperative, a large Seattle-based integrated delivery system, and found that it produced higher-quality care, more patient satisfaction and enough cost savings to convince Group Health to spread PCMHs to all 26 of its medical centers. For every dollar Group Health invested, it recouped $1.50, largely by reducing emergency room and hospital use.
PCMHs are not new—the concept dates to the 1960s as a way to care for special needs children. "The biggest challenge to medical homes is payment," notes Michelle Shaljian of the Patient-Centered Primary Care Collaborative, an advocate for PCMHs. Fee-for-service payment, which encourages more costly specialty and acute care, has long prevented primary care practitioners from reorganizing their practices to better serve patients. Traditionally, doctors do not get paid for educating patients or coordinating their care, only for providing services, tests and treatments.
With health care costs rising sharply over the last decade, health insurers started using incentives and risk-based payments to slow fee-for-service cost growth. Insurers, like Wellpoint, also started paying a bonus to primary care practices recognized as PCMHs by the National Committee for Quality Assurance (NCQA), a national accrediting body, in hopes that the approach could improve overall health and lower costs.
Medical homes are seen as a way to reinvent primary care and improve the quality, cost and patient experience. Since 2007, more than 5,700 medical practices have become NCQA-recognized PCMHs. Medical homes got an even bigger boost under the Affordable Care Act, which directed Medicare to fund several pilot programs to bolster primary care.
One such effort has Medicare paying 1,200 medical practices in eight states to provide health care in a PCMH to more 900,000 beneficiaries. Those federal government-funded pilots found to improve health care and lower costs can be rolled out nationwide through two of America's largest health care insurers, Medicare and Medicaid. Boosting the stock of PCMHs is part of Obamacare's effort to spur changes in how health care is paid for—away from costly, piecemeal payments to global or fixed payments that force providers to focus on quality and improved patient outcomes.
Because the number of PCMHs only really started increasing in 2010, the body of conclusive research on medical homes is lacking. They are shown to increase care quality, boost patient satisfaction and lower costs in integrated delivery systems like Group Health, where health plans, doctors and hospitals are jointly owned. But there are substantial costs involved in a PCMH. Group Health, for example, has 400,000 members in medical homes; they invested an additional $16 per patient per year in added staffing for its prototype, not counting sizable investments in information technology.
Whether they can do the same in stand-alone medical practices and other settings still is up for debate. Many insurers, doctors and even hospitals are betting that PCMHs will cut hospital-related costs and eventually lead to reduced illness via their focus on primary and preventive care. As most health insurers and payers roll out risk-based forms of payments to providers, even hospital systems are sponsoring PCMHs.
Brigham and Women's Hospital is one, sponsoring medical homes around Boston like its Advanced Primary Care Associates, South Huntington, in city's Jamaica Plain neighborhood. "I give Brigham and Women's a lot of credit," says clinic medical director Dr. Stuart Pollack. In the two years it's been open, preliminary results show that hospitalizations among the clinic's patients have dropped in half.
A hospital's bread and butter are patients in beds. But as payers in Massachusetts are holding hospitals and other providers accountable for patient outcomes, Brigham and Women's has given up doing business as usual. Many patients at the South Huntington branch lack transportation or must choose between paying for food or medication. "We have people working your housing issue and food issue," says Pollack. Care is set up for the convenience of the patient, not the provider. Instead of referring out those patients who need mental health care, the clinic has brought behavioral health professionals on site to ensure patients get the help they need, which can prevent costly trips to the emergency room or hospital.
Gone are bankers' hours, days- or even weeks-long waits to see the doctor, and playing phone tag to get test results. "We have same-day services for established patients," notes Pollack. The clinic closes to patients for two hours every Wednesday afternoon so clinic staff (all of whom are employed by the hospital) can do a "population huddle." One late August afternoon, the clinic's team ran patient registry data to find which diabetics lacked recent cholesterol and blood-sugar screenings. Doctors, nurses, pharmacists, and front-office staff contacted a dozen patients to wrangle them in.
One of the nation's biggest medical home rollouts is throughout bucolic Vermont, which has enlisted commercial, state and federal health care payers to support PCMHs so all Vermonters have access to a continuum of seamless, effective and preventive health services. In its fifth year, the state's Blueprint for Health finds most residents getting care in a PCMH (most of Vermont's primary care practices are PCMHs), which are aligned with hospitals and so-called community health teams. The teams, comprised of nurses, pharmacists, social workers, mental health professionals, health coaches and others, support primary care providers and their patients.
In remote St. Johnsbury, the local team works with Angie Moulton, 40, to keep her lupus in check, ensures she has a machine to check her blood levels weekly at home rather than traveling to Northeastern Vermont Regional Hospital, pays for a taxi to get her to healthier living workshops, and even helped the mother of two get presents for her kids during their first Christmas in Vermont. "We were able to have a Christmas because of them," says Moulton, whose family relocated from Florida last year.
"The team will make sure someone's needs are met," notes Laural Ruggles, project manager for the community health team in the St. Johnsbury region. The teams ultimately help patients self-manage their health. Anyone can seek assistance from a community health team, regardless of whether they have insurance or not. The state, Medicare and commercial insurers all contribute to support extra payments—ranging from $1.30 to $2.45 per patient per month—to PCMHs and to help fund the community health teams that dot Vermont, extending the reach of the primary care practices.
A five-year review of the program showed a slowing in growth of health care costs and hospitalizations and favorable results for preventive and effective care measures. The review noted that the program could further lower emergency department visits and boost eye exams for diabetics, but overall many PCMH patients were positive about the improved service. "I couldn't ask for a better health care team than what I have in Vermont," says Moulton.
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