The Best Care Anywhere

I recently had an interesting encounter with a long time friend and colleague who left his private practice of family medicine and started work for the Veterans Health Administration in one of their new community primary care centers. "How's it going", I asked. "Are you happy in your new position?" I believe that his answer to me is something that everyone needs to hear.

My friend explained that the uncompensated hours he used to spend in his private practice dealing with administrative issues, multiple insurance requests, and conflicting drug formularies are now a thing of the past. "Unlike my life in private practice, my time is now completely devoted to the care of my patients, and collaboration within the practice on how to make our care better. I have scheduled time throughout the day to catch up on needed paper work and administrative duties, and we also have planned collaboration sessions with other VA health care professionals to learn and plan our team work for patient care".

The VA, once maligned in previous generations, has been quietly at work, transforming itself into what many now believe is the the highest-quality healthcare provider in the United States. They have done this by emphasizing access to primary care, creating health care teams that learn how to coordinate their care, and paying attention to the scientific evidence of what does and does not work for patient benefit. As a result, our United States Veterans Health Administration has become the only fully functioning, evidence-based healthcare system in the entire country.

Unfortunately the transformative changes in the VA are impossible to duplicate in our current private system, because of the way our current system is set up. As a doctor who works on healthcare improvement issues everyday in the real world, I have learned that the biggest barriers I face are insurance companies and the lack of planning and coordination among those who work in healthcare.

So, what are the lessons for us who struggle outside of the VA system as we plan for healthcare reform? For me, the answer seems clear:

Personal medical home - use this full service , primary care model as the template to deliver and organize our care
Payment reform - value the doctor's time and reward quality instead of volume
Use information technology - in a systematic and intelligent way to track care, identify outcomes and interact with our patients
Plan intelligently - so that needed access to care is available
Allow doctors time - for the planning and care coordination that is so necessary to improve their care and so undervalued today.

A great book to learn more about the change in the United States Veterans Health Administration and how it compares to our overall health care system is Best Care Anywhere: Why VA Health Care is Better Than Yours, by Phillip Longman.

Have we reached the tipping point in Health Care Reform?

Just maybe! This interesting article from "The Medicaid Front Page", makes the case. Time will tell!

http://www.medicaidfrontpage.com/2009/03/us-healthcare-and-reform.html

What does the Election of Barack Obama Really Mean for Health Care

We have chosen Barack Obama as our next President! This means that his proposal for how to reform health care will certainly set the tone for our discussion about how to improve quality, cut rising costs and extend medical coverage to about 45 million additional Americans.

Since any proposal must be submited to Congress, it is reasonable to assume that elements of Obama's proposal may well be modified, but at the core of his proposal are principles that would change health care delivery and coverage in the U.S.

The cornerstones of Obama's plan are:

• Expand Medicaid eligibility to include greater numbers of the uninsured
• Mandate coverage for children
• Create a national exchange where uninsured folks can purchase a public or private policy;
  
• Provide subsidies to lower-income individuals and small businesses to help defray the cost of purchasing insurance; and,
• Tax medium and large-size employers that decline to provide their employees with health insurance.

Of crucial importance in all of this is the need for us to remember that quality of care, and value for the money we spend, must be improved dramatically for any plan to be truly successful. Obama has chosen great advisers who understand this, but there is great danger that economic concerns could drive attention into only cost cutting steps, without insuring that we adequately pay for improved access and provision of primary care services. We could do the most to improve access and quality, while simultaneously lowering costs, by supporting legislation requiring all plans to provide payment for the personal medical home. Simply expanding programs like Medicaid, without this type of reform, will fail, since they do not pay primary care physician adequately for providing the care!

We have discussed the specific benfits of the personal medical home previously, and it is important to remember in a time of scarce resources, that by supporting the provision of primary care first, we are supporting the only thing that has ever been shown to be associated with both improved quality and decreased cost of medical care! Although well intentioned, throwing more money at our current health care mess will be bound to dissapoint us, by making more people eligable for the dysfunctional, and unorganized type of care that is currently bankrupting us.

How do people in different countries view their health care ? How do their opinions compare to those in the US?

As we debate how to achieve an improved health care system for the United States, the opponents of change often raise the specter of "socialized medicine", and invoke stories about the horrible care and service in other countries. What has been lacking in this discussion is, how do the residents of the United States and other countries actually feel themselves about their experiences within their respective health care systems?

A new seven-nation survey has just been released by The Commonwealth Fund. It shows that U.S. adults were the most likely to say they experienced medical errors, more likely to report they went without care because of the cost, and more likely to feel the health care system needs to be rebuilt completely. The results, are published in the journal Health Affairs.

The article, Higher-Performance Health Systems: Adults' Health Care Experiences in Seven Countries, 2007, also shows that U.S. adults have the highest out-of-pocket costs and the greatest difficulty paying for needed medical care.

The survey was conducted among 12,000 adults in Australia, Canada, Germany, the Netherlands, New Zealand, the United Kingdom, and the United States. One-third of U.S. adults surveyed called for rebuilding the system, and this was the highest rate of any country surveyed. In addition to cost concerns, the experiences of U.S. patients indicated more fragmented and inefficient care in the U.S., including medical record and test delays.

Commonwealth Fund Senior Vice President Cathy Schoen, the lead author of the study, said "Patients in the U.S. are frustrated by high costs and a complicated health care system,".

The survey also examined the experiences of adults who have a "medical home", which was defined in this study as a regular source of care that is accessible and helps coordinate their care. Across all seven countries, only about half to 60 percent of the adults reported having such a relationship with a health care provider. In each of the countries in the survey, those adults who did have a medical home reported a significantly more positive care experience.

Food for thought as we discuss how to improve our system!

What Care Enhancement Services justify enhanced payment ?

In my last post, we discussed the orientation and philosophy of the personal medical home, as advocated by the American Academy of Family Physicians (AAFP) and the American College of Physicians (ACP). A reasonable question to ask is, what exactly is being done by the doctor and staff that justifies enhanced payment to the physicians office? What are the services that do not fall into the usual payment for an office visit?

Recently, my medical group entered into a pioneering contract with a Medicare Advantage insurance company to hammer out these details as part of a new Medicare Advantage plan. Here is what we came up with:

Personal Medical Home Care Enhancement Services

• Maintain the patient's "personal medical home" electronic health care record, which includes an updated medication list, problem list, and records of all care provided and summaries of care received outside the family physician's office.

• Systematically remind members of covered preventive screening services.

• Apply the Wagner Chronic Care Model of pre-planned office visits to provide medical care for chronic conditions. This model includes the following:

1. A registry system for chronic conditions including but not limited to congestive heart failure and high-risk diabetes, that allows the medical team to identify patients with chronic conditions, assure that the needed care is delivered, and recall the patients for the regular follow-up care necessary for their condition.

2. Software for decision support, available in the room at the time of care. Family Care Network has invested in computerized software that provides evidence-based guidelines for care in the room for patient and health professionals to utilize at the time of services. This software also allows health professionals to link on the web to medical library services from the exam room.

3. The use of clear patient-friendly tools to enable patients to understand their chronic conditions and the actions necessary for them to achieve optimal health.

4. The use of clinical staff to support the patient in self-managing and telephone support, depending on the patient's needs.

• Provide regular quality reports (as agreed) for the insurance companies patients.

• Conduct an annual risk assessment for each member at which time the member's chronic medical problems are identified, reviewed and updated.

• Maintain the patient-doctor health care relationship between office visits by using telephone care and the Doc InTouch secure web messaging system when appropriate. This will enable more frequent interactions with the health care team to facilitate patient self-management.

These "deliverables" for the insurance company are value added work that is in addition to what is normally expected. Taken together, these measures provide a concrete framework that allows for much better patient management, and patient outcomes. If this approach was emulated nationally, it would go a long way to improve our national health care scorecard, and at the same time dramatically improve the financial health of family physician offices.