I very much respect my primary care physician and her advice on my health does make an impact on my actions. Once I told her that my knees were hurting a bit and I asked her what I should do. She took out a note pad and scribbled on it and handed me the paper. On it, in big bold letters she had written, “EXERCISE.” I laughed. She then added that if I lost just 10 pounds she could promise me the pain would disappear completely. I took the message to heart and followed her recommendation; she was right.
I don’t bring this up because I think hospitals or health system should open weight loss clinics—although my colleague recently wrote an interesting column on this topic. I recount this story, as part two of my look at the patient-centered medical home. These days, what my doctor did, now nearly eight years ago, is still somewhat out of the norm.
In a fee-for-service reimbursement environment, it isn’t beneficial for me to get well, or in this case fit—especially if I do it without the help of my healthcare provider. However, in the coming years, how you are reimbursed will change and you will be penalized if your patients’ health continues to decline—especially those with chronic health issues. Right now, medical homes nationwide are gathering data to see if their work will help reduce readmission rates.
Although it makes logical sense that by maintaining the health of chronic care patients they will have fewer trips to the hospital, as of yet there is no hard data supporting it. Watch for that information in the next year or two though. Last week we looked at how one program had created a sort of self-sustaining version of a medical home by keeping the same number of staff and increasing preventive care. But is that approach possible in all circumstances? It’s a question healthcare leaders are exploring through pilot programs in nearly every state as they try to determine the best way to run a medical home.
In Maine, Penobscot Community Health Care is one of them. In 2009, three of Penobscot’s offices were chosen to participate in the Maine patient-centered medical home pilot project, though they decided to roll it out in all four offices. Here’s how they are approaching this task and where they are finding successes and challenges.
Robert Allen, MD, executive medical director at Penobscot, explains that the first step they took was to hire four nurse care managers. Using data from its EMR, the team identified patients who were struggling with specific conditions, such as diabetes. The team also approached physicians to ask for their insights on who could benefit from the program—a key component, Allen says, for buy-in.
“Whether the patient has been in the ER, admitted to the hospital in the last six months, or if the primary care physician just felt they could benefit from the care manager because they were a frequent visitor or had a lot of questions, those where the people we looked at,” says Allen.
Once they started gathering data and speaking with patients, they realized that four care managers weren’t enough to handle the number of patients who needed outreach. So they hired four health coaches and a medical assistant to help with panel management.
“Right now that’s all funded through grants. But as we continue with this, one of our major concerns has been, the more we do this, the more we like it, and we’re worried about the financial sustainability of this long-term,” says Allen. “We hope there will be a change in how medicine reimburses because of all the pilots that are doing patient-centered medical home, and that they [payers] will save a huge amount with it.”
In Maine, Allen explains, the Maine Health Management Coalition is working with the Maine Quality Forum Advisory Council, the insurance companies, the providers, and the local business to encourage payers to change how physicians are reimbursed to allow the medical home to continue.
“This is a proactive state and we tend to work together. But we need to find a different reimbursement structure in the next couple of years. If we don’t [change] it will put this [program] at risk,” he says.
Though they have no way of knowing what will become of the financial side of this pilot, Penobscot continues to cultivate their program. After adding staff, the next task they undertook, not unlike Southern Maine Medical Center PrimeCare Physicians, was to improve access and get to same-day service of the patient.
When the Penobscot team started, patients sometimes had to wait nearly three months for a follow-up appointment to see their primary care physician. To address the problem, the first step was to open up access. Penobscot did this by expanding office hours to meet the demand, explains Hilary Worcester, a practice manager at Penobscot. They added some weekend hours and extended care until 8 p.m. in the clinic.
“Now when a patient comes in the same day, they are surprised they get to see their own doctor,” she says. “But it adds to the continuity of their care if the patient gets to see the primary care physicians.”
While correcting the access issue was done in short order, one part of the medical home pilot directive that the team continues to struggle with is the creation of a patient advisory committee. “Finding patients who want to meet every other month to talk about things in our practice and what you can do better for them has been a real challenge,” says Worchester. And it’s an area Penobscot continues to try to address.
Overall, though, the pilot has helped Penobscot refocus efforts toward treating the whole person, says Allen.
“The medical home concept has a warm feel to it, too,” adds Worchester. “But now we also have more eyes looking at things. Between the care managers, the health coaches, nurses, and physicians, we can spot gaps in care and identify and treat all of the patient’s needs.”
While the financial benefits and long-term viability of the medical home is still unclear, those practices that participate in the pilots say the benefit to their patients’ overall health is generally positive. As hospitals and health systems press onward into the next era of healthcare reimbursement, this is certain: The fee-for-service methodology won’t help the patient’s health improve or the health of the bottom line.
Karen Minich-Pourshadi is a Senior Editor with HealthLeaders Media.
