How Does The Patient-Centered Medical Home Transform Health Care Delivery?

Can Patient-Centered Medical Homes Transform Health Care Delivery? The answer is clearly yes, and that is a point I have tried to emphasize, but I often get asked by those less familiar with the subject, how does this really make a difference?

The basic idea in a nutshell is that in order to be effective and add value, health reform must deliver a new delivery system built on a solid foundation of primary care. There are two barriers to this happening:

• We are losing primary care providers, and very few new doctors are in the pipeline to replace them
• The way primary care doctors are paid is inadequate and dysfunctional, so that they are not paid for the work that patients truly need and want them to do.

The medical home is an approach to primary care organized around the relationship between the patient and their personal physician. It is is primary care that is "accessible, continuous, comprehensive, family-centered, coordinated, compassionate, and culturally effective.” It has now been endorsed by important, independent health care think tanks, such as the Commonwealth Fund.

In 2007, four primary care specialty societies, representing more than 300,000 primary care specialists, issued a joint description of the Principles of the Patient-Centered Medical Home:

• A personal physician;
• A whole-person orientation;
• Safe and high-quality care (e.g., evidence-based medicine, appropriate use of health information technology);
• Enhanced access to care; (e.g., phone visits, secure web visits, group visits with appropriate use of health information technology);
• payment that recognizes the added value provided to patients and insurers who have a patient-centered medical home.

Today, few Americans say they have a source of care with these features, but I am proud to say that my medical group, Family Care Network, has made wonderful progress to become a full fledged Patient-Centered Medical Home for our patients. We now know what works. There is no excuse to delay. If we do not move forward in this effort, we will continue to reap the whirlwind of spiraling costs and plummeting value. Primary Care will disappear. Now is the time.

The need has never been greater

My grandfather was a physician in general practice at the beginning of the last century, before the Flexner Report revolutionized medical training and brought medical education into the scientific age. His office was in the bottom of the family home. My grandmother would open the door, folks would come in, and the agenda was whatever was on the mind of the person who came. There was no phone interuption (there were no phones!), record keeping was easy (20 years on one 3 by 5 card), and most modern therapies had not yet been invented.

Today, many physicians in primary care continue to practice in the same basic style as my grandfather. They wait in their office to see what comes, and are only paid for this visit "piece work". It is as if the telephone was never invented, much less the Internet! They do not manage their patient panel in such a way as to improve their overall care, because they do not have the tools to know how the group is doing, and indeed, they may not even have thought about it.

Recently, Dr. Kevin Grumbach, professor and chair of the Department of Family and Community Medicine at the University of California, San Francisco, has renewed the call for a thorough "Revitalization of Primary Care". He correctly notes that the traditional model of primary care has not been very well supported by payers, purchasers or government agencies, and that people are turning away from it. In a recent article, he is quoted as saying, "This model of 19th-century practice -- of the doctor in the office and patients coming in -- is not going to work in the 21st century. We have come to the proverbial fork in the road." He identifies physician payment reform as one of the first steps we must take in revitalizing primary care, to provide the personal medical home. This is the work that we have been engaged in at Family Care Network.

Dr. Grumbach notes that the worsening shortage of primary care physicians is fueling "medical homelessness," which leaves patients without adequate access to primary care services and patient-centered medical homes. This is particularly tragic, since the ratio of primary care doctors to the population is the only statistic that has ever been shown to correlate with both improved health care quality and decreased cost of care. We must change now. The need has never been greater.

A CHANGE IN THE FACE OF MEDICINE

This article was written by family physician David H. Hopper MD, from Princeton, WV, upon the occaision of his premature withdrawal from Family Medicine practice. It is an eloguent testimonial to something that is happening all over the United States. The article appeared in the Bluefield Daily Telegraph.

A CHANGE IN THE FACE OF MEDICINE

Change is always difficult, yet as it says in the Bible, Ecclesiastes 3:1 “There is an appointed time for everything. And there is a time for every event under heaven.” After almost 30 years of serving the people of Princeton and the surrounding region, change took place in the lives of many in this community with my closing of Total Life Family Practice.

This decision was not an easy one, for my partner and I have enjoyed many good years caring for our patients through this practice. However, despite the governor’s logo, we are no longer “open for business.” With this closure over a dozen jobs have been lost and many thousands have lost their family doctors.

The demands of the practice of medicine are continuing to grow. Managing piles of paperwork, dealing with drug formulary and insurance issues, meeting rising overhead with inadequate reimbursement from Medicare, Medicaid and insurance companies, paying high WV malpractice insurance premiums and handling numerous other issues make private practice increasingly difficult. These problems are nationwide, but seem to be even worse here in WV.

Over the years 8 physicians came and left the practice, all of whom moved out of state. Recruiting and retaining doctors became increasingly hard. It became progressively harder to take time off to follow other callings such as my medical mission trips to Sudan or other misfortunate places. Finally I made the extremely tough decision to close my practice.

My decision was an individual one and certainly does not apply to all primary care doctors, but it is one that seems to be increasingly common. The private practice of family medicine has become less and less appealing. The joy of long term patient care relationships, the fulfillment of knowing that you had been able to manage multiple problems which would have required visits to numerous specialists, and the pleasure caring for the children of children you delivered is still available to the family doctor. However the stress of the system, which has persistently undervalued primary care services, has led shrinking percentage of new graduates to enter these fields.

In a recent issue of CA: A Cancer Journal for Clinicians, Dr. Richard Wender, President of the American Cancer Society said: “Adults with a primary care physician as their personal physician are 19% less likely to die prematurely than individuals who utilize a specialist as their personal physician.” And “Despite the striking evidence of the critical role played by primary care clinicians in the cancer fight, the future of primary care services in the United States is uncertain. Several high profile publications have questioned whether we are facing ‘the end of primary care.’ ”

Change will continue to take place in American healthcare, and it must. However it is sad to see the most personal aspect of the healthcare system die off. Be thankful for your family doctor, and support a system that allows whole person medicine to survive.

The Medicare Crisis, National in Scope, Local in Impact

Medicare was founded in 1965 to help cover the costs associated with health care for older Americans and those with certain disabilities. Since that time it has evolved into one of the most needed and important programs in U.S. Government history. Unforunately, however, as our nation’s health care system now braces for a Medicare Population explosion, caused by the Baby Boom Generation aging into Medicare, primary care medicine finds itself on the verge of collapse due to drastically insufficient Medicare reimbursement.

Some Medicare beneficiaries have already felt this on a personal level, as they have had difficulty finding a family doctor for their primary care needs. This is due to the fact that Medicare funding for the services provided by family physicians often does not cover the actual cost to the doctor of providing that care! In fact, according to a 2006 report from the American College of Physicians, "Primary care is on the verge of collapse. Very few young physicians are going into primary care and those already in practice are under such stress that they are looking for an exit strategy". The report further notes that the key contributor to the problem they describe is the "inadequate and dysfunctional payment policies" of the government and insurance companies. "Unless immediate and comprehensive reforms are implemented by Congress and CMS (Medicare), primary care - the backbone of the U.S. healthcare system - will collapse," concludes the report. "The consequences will be higher costs and lower quality as patients find themselves in a confusing, fragmented, over-specialized system in which no one physician accepts responsibility for their care, and no one physician is accountable to them for the quality of care provided."

The problem described in this report is very familiar to your family doctor, and all of us here in my practice at Family Care Network (FCN). A Family Medicine practice is really a small business which simply cannot remain viable if revenue does not exceed expense. If the current inadequate and dysfunctional Medicare payment policies continue, and with the Medicare population about to increase dramatically, doctors will have no choice but to close their practice to Medicare patients. It is simply not possible for physicians to subsidize the care of so many without becoming economically non-viable. This is a terrible prospect, at the very time when the need will be the greatest! I believe that this is unacceptable, and that is why I am sharing this information about steps we are taking in my medical group, The Family Care Network Solution.

Family Care Network (FCN) has been working diligently to bring this crisis to the attention of our elected officials. While we sincerely hope that our State and Federal Governments will eventually address this crisis on both a national and local level, we have taken a position that FCN must seek out a more immediate solution to ensure our long term viability for survival.

FCN has developed a long term strategic plan for Medicare which we believe will enable us to:

1. Remain in Practice.
2. Continue practicing family medicine according to the Personal Medical Home model of health care as advocated by the American Academy of Family Physicians (AAFP) (see next page).
3. Continue providing care for our existing Medicare Patients.
4. Care for existing patients who become Medicare eligible.
5. Accept new Medicare patients into our practice (beginning in 2007).

The central component to the FCN Medicare Strategy is partnering ONLY with Medicare insurance companies that recognize the critical role played by family medicine in the overall health care system, and choosing ONLY insurance partners that financially support the "Personal Medical Home" as advocated by the AAFP and ACP.

We realize that patients have different needs and preferences when it comes to their Medicare health insurance. As such, FCN will provide our patients with access to multiple Medicare insurance plan options. We also recognize how confusing Medicare insurance has become and therefore FCN will provide insurance counseling services at no cost to our patients. Licensed insurance professionals well versed in all of the various Medicare insurance plans accepted by FCN, will be on-hand to help you understand your options and enroll in the Medicare insurance plan that is best suited to your personal needs.

Finally, FCN believes that healthy communication correlates directly to healthy patients. FCN requires that all Medicare insurance company partners provide internet connectivity between patient and provider via the DocInTouch web messaging program, at no cost to the patient. DocInTouch is a secure internet-based service that enables patients and physicians to communicate efficiently and effectively, and this type of functionality is part of the personal medical home concept.

The Personal Medical Home

All physicians and staff at FCN firmly embrace and support the Personal Medical Home model of health care advocated by the American Academy of Family Physicians (AAFP). FCN supports the Personal Medical Home in the following ways:

1. The physician makes a commitment to the patient to know them as a person, and to provide ongoing, continuity of care for illness and injury, as well as medical planning and advice for screening for illnesses and maintenance of good health.
2. Our office team shares this commitment, assisting the physician in providing hospital care, home care and consultation when needed.
3. Maintain accurate medical records for the care delivered and provide patient education using current technology.
4. Maintain patient registries for certain chronic diseases (Diabetes, Congestive Heart Failure) in order to study, monitor and improve the adequacy of their care, as well as to seek out patients who have not received needed care.
5. Provide planned chronic care visits for diabetes and other appropriate conditions, so that needed information is present for treatment and education at the time of the visit.
6. Integrate patient feedback to improve the performance of the practice.
7. Implement the “New Model of Family Medicine” described in the Future of Family Medicine Report, including secure web messaging.

As we communicate with our patients about these changes, we are letting them know that we greatly appreciate their continued support and patronage. Providing their Personal Medical Home is something that we take very seriously and we remain fully committed to providing the absolute best primary care medicine possible. We recognize that re-evaluating Medicare insurance needs involves significant effort, time and stress. We hope that they understand the challenge we are currently facing, but with stheir support we are confident that we will overcome this challenge, together.