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.

We are witnessing a Battle for the Soul of American Medicine

The title of this column is a direct quote from an insightful article in the New Yorker magazine, June 1, 2009, page 36, written by Dr. Atul Gwande, entitled "The Cost Conundrum, What a Texas town can teach us about health care". Read this article!

"Somewhere in the United States at this moment, a patient with chest pain, or a tumor, or a cough is seeing a doctor. And the damning question we have to ask is whether the doctor is set up to meet the needs of the patient, first and foremost, or to maximize revenue.

There is no insurance system that will make the two aims match perfectly. But having a system that does so much to misalign them has proved disastrous. As economists have often pointed out, we pay doctors for quantity, not quality. As they point out less often, we also pay them as individuals, rather than as members of a team working together for their patients. Both practices have made for serious problems."

AMEN.

So Who Opposses Health Care Refrom These Days?

The news has recently contained several stories which note that many prior opponents of health care reform are now "working together" in common purpose to help bring needed change. At the same time, we are now starting to see anti-reform television advertisements that warn against "any form of government-run health care". The most widely available ads come from an organization that is calling itself "Conservatives for Patients' Rights ". If you believe in Santa and the Tooth Fairy, you might also think that a group of citizens spontaneously got together to educate the the reat of us, but the reality turns out to be far different! Conservatives for Patient's Rights is bankrolled and founded by a guy with a past named Rick Scott, best known for heading a company that paid the the largest health care fraud settlement in US history. Scott was a healthcare executive who grew Columbia Hospital Corp. from two El Paso hospitals in 1988 into the nation's largest investor-owned hospital chain and the world's largest healthcare company.

Columbia later merged with HCA, and Scott was forced out in 1997. Subsequently, a government investigation into HCA resulted in HCA paying $1.7 billion dollars in civil and criminal charges to settle the largest health care fraud settlement in US history, but Scott was not charged individually. He now owns a controlling interest in Discovery Health, and is the Chair of a chain of an urgent care center chain in Florida known as Solantic Corp.

As you watch the adds bankrolled by Scott and his Conservatives for Patient's Rights, you will notice broad statements that really have nothing to say about what is being proposed now for the US. Instead, he strives to create fear of change and rails against the "nanny state" "taking choice out of health care" and other vague notions, while quoting folks from Canada or the UK about problems they perceive in their countries' systems. You would never know to watch these ads that the proposals by the current administration adhere to the 4 pillars of reform that Mr. Scott advocates, which include choice, competition, accountability and responsibility . He forgot to mention equity, effectiveness, affordability and universality, however.

Take care as you watch these ads! Ask who paid for them, where they come from and what the sponsors have to gain by blocking meaningful reform. As President G.W. Bush once tried to say, "Fool me once, shame on you, fool me twice, shame on me!"




A Practical Approach to Health Insurance reform

When it comes to change on a national level, new ideas and needed reform proposals often come from the states. Maybe that will now happen with health care insurance reform.

On May 18, the Whatcom County Medical Society hosted a presentation by Washington State Insurance Commissioner Mike Kreidler, who accepted our invitation to speak to us about his innovative and practical plan for health insurance reform in Washington State, known as the Guaranteed Health Benefit Plan. As insurance commissioner, Kreidler has developed a wealth of knowledge, that includes experience running a health insurance company when KPS Health Plans were put into receivership. He has clearly put his experience to good use in the design of this plan.

Commissioner Kreidler’s Guaranteed Health Benefit Plan would provide health care coverage for all Washington residents up to age 65, by virtue of residency in the state for one year, while it also preserves the individual's freedom of choice to pick the plan they want. Keidler described how it would work:

• All residents get catastrophic coverage for health care costs exceeding $10,000 a year.
• Limited preventive care is covered, which includes an annual checkup, immunizations and age-appropriate cancer screenings.
• Funding comes from a payroll tax, shared by the worker and employer.
  
• Consumers and employers can choose additional coverage for other care from any insurance plan serving the state, and costs will be much less, since the roulette wheel of catastrophic cost has been removed.
• All insurance "customer service" – both catastrophic and routine, is provided by the private insurers.
• For expenses in excess of $10,000, the insurance company pays at their contracted rates, and deals with the state for the payment to them
• Individuals with no coverage of any kind are at leas covered for some preventive care, and all "catastrphic" care that exceeds $10,0000.

Commissioner Kreidler's approach is refreshing and very interesting. He builds on the structure we have now, while the plan causes minimal disruption to the existing system, extends coverage to all without mandates, and yet still respects choice in the system. It is a way to get moving on this important issue now. As he noted in his talk, all advanced countries have migrated to their own health care systems by building conservatively on the unique features of their pre-existing systems, and it is unlikely that we will have reform as a "big bang" event.

After his talk, Commissioner Kreidler left to fly to Washington, DC for talks with key legislators there. As the health care debate continues, I think that his is a welcome voice for common sense. and a practical choice to help people quickly!

You can get details about the plan by clicking here.

PM Bellingham Discussion on KGMI

I had a very stimulating conversation about health care and our need for reform on the PM Bellingham radio program, hosted on KGMI radio by Jacqueline Cartier and Ken Mann. They asked great questions, and gave refreshing insight from a younger person's perspective

PM Bellingham Radio Program Link Click Here

Healthcare US Cost-to-Value Ratio Punishes Business

Each year, the CEOs of major US companies gather for the Business Roundtable, where they discuss serious issues affecting business. So what are they talking about during the worst economic crisis in generations? Health care! And their consensus is that our "dismal state of health care" affects our global competitiveness and the national economy. Their conclusion is based on the cost-to-value ratio that compares the dollar amount spent on health care in the US with the value received for that care. When comparing the dollar amount spent to the health of the citizenry, the roundtable findings show:

• $2.4 trillion a year is spent on health care in the US
• On a per-capita basis, that’s $1,928 per person for 2006
• $1,928 per capita is 250% more than any other nation spends
• On a cost-to-value basis, the US is 23 points behind its five top economic competitors (Canada, France, Germany, Japan, and the United Kingdom)
• The governments of these five nations play a bigger role in their healthcare systems than the US does, although each nation operates on a different healthcare system
• The US is 46 points behind its closest emerging competitors (Brazil, China, and India).

I may sound like a broken record, but our health care problems are not just about cost. We are definitely not getting value received!

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 Nation Think about Health Care Reform?

In December, the Presidential Transition Team invited Americans to host and participate in health care community discussions, and the employees and staff of Family Care Network were a part of that process. The idea was to for small, local gatherings to discuss health care, identify what's broken, suggest ideas to fix it and submit responses to the Transition Team for analysis of the nations feedback.

On March 5, Health and Human Services issued a special report of the community discussion outcomes. Over 9,000 Americans in 50 states and Washington, DC signed up to host a forum and 3,276 group reports were submitted to the Transition Teams special website (www.change.gov).

The report shows that America’s concerns and views are very similar to the discussion that we had here at Family Care Network. Concerns focused on access to health insurance, rising premiums and high drug costs, and the “broken” health system, with poor access to primary care, and lack of affordability. Also of concern was being “under insurable,” medical mistakes and the system not being “for them.” Of the groups reporting cost of health care concerns, 28% focused on health insurance premiums and another 28% focused on the overall cost of the system.

The solutions suggested by the reporting groups highlighted the need for a system that is fair (36%), patient centered and choice oriented (19%), simple and efficient (17%), and comprehensive (15%). Fairness was a very common theme, and our current "system" was perceived to be quite "unfair". Some respondent groups said that health care should be considered a basic right, not a privilege and many felt the system should insure all Americans.

The analysis of responses found there were no significant differences in opinion based on rural or city location, region of the country, average income or employment status. The only exception noted was that those who represented the health care field expressed more concerns with provider shortages, the lack of a “system,” inadequate research, payment rates, medical malpractice, inefficiency of the system, and inadequate treatment of mental health.

If you are interested in reviewing the detailed report visit: www.healthreform.gov.

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.

Flight of the Doctors

Jason Hwang has noted the recent, dreary evidence that primary care doctors are disappearing from the scene, and he correctly writes about the need "to encourage business models that reduce paperwork and red tape, while rewarding lifelong wellness care – the core tenet of primary care medicine."

I have written a comment on his blog, however, since I believe that he misses the importance of having independent primary care as a needed protection for patients.

Read more here: Flight of the Doctors by Jason Hwang