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INDIANAPOLIS (AP) — A budding model for primary care that
encourages the family doctor to act as a health coach who focuses
as much on preventing illness as on treating it has shown promising
results and saved insurers millions of dollars.
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Growth in emergency room visits and hospital admissions slowed and
prescription drug costs have been tamed with this approach, known
in the industry as patient-centered medical homes, or just medical
homes.
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The current health care system pays doctors to see patients and
largely attend to their immediate needs. Patients may get
treatment, advice, a prescription and a follow-up
appointment.
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Patient-centered medical homes focus on keeping patients healthy,
which saves money by reducing hospital visits, especially for
chronic conditions such as diabetes.
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WellPoint Inc., UnitedHealth Group Inc., and other insurers have
pilot projects around the country testing this concept. The
departments of Defense and Veterans Affairs are making plans to use
medical homes, and more than a million Medicare recipients are
involved in another test.
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All told, an estimated 40,000 primary care doctors work in
practices set up as patient-centered medical homes, according to
the Patient Centered Primary Care Collaborative. That amounts to
about 13 percent of all doctors and pediatricians.
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Michigan’s largest insurer says it saved $65 million to $70 million
last year through its medical-homes program. But the idea requires
big changes to traditional primary care, and experts say that may
slow its growth.
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Patients say they like the greater involvement of their
doctors.
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Richard Smith of Vidor, Texas, who has multiple sclerosis and knee
and ankle problems, once struggled to walk to his mailbox. Now, he
walks three to four miles a day. He’s dropped 40 pounds in two
years, and his blood pressure and cholesterol are down.
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He credits Dr. James Holly and a medical home practice. Holly
ordered braces for Smith’s legs, encouraged him to exercise and
introduced him to a dietician. And the doctor called Smith once in
a while to check in.
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“He really touches base on everything, my health, any kind of
problems I have,” he says. “He’s worried about my whole
life.”
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Under the medical home approach, doctors use electronic records to
track patients between visits and act as the central point of
communication between specialists, nutritionists and others. They
monitor blood pressure, blood sugar and other tests and whether
patients are exercising and taking their medication. They also
exchange emails with patients.
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Instead of simply telling someone to exercise or stop smoking, a
doctor or member of the patient’s care team might devise a plan
with the patient and then check to see that he sticks to
it.
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Patient-centered medical homes started in the late 1960s to help
children with complex medical problems. The concept took off in
primary care a few years ago, as insurers and doctors looked for
alternatives to a system with soaring costs.
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“The irony of medical care is that people are their own doctor 99
percent of the time, and what we don’t do well is help that person
be the best doctor they can be,” says Dr. Dave Lynch, whose
Bellingham, Wash., family practice has operated as a medical home
since the late 1990s.
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The concept depends on doctors and other care providers doing more
than they normally might in primary care. Don Jacoby of Cincinnati,
for example, woke up the day after knee surgery in January to find
his primary-care doctor standing next to his hospital
bed.
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The doctor had set up Jacoby’s appointment with an orthopedic
surgeon and then visited afterward to see how he was doing. It
reminded Jacoby, 67, a retired teacher, of the family doctors he
knew growing up in a small Pennsylvania town.
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“He knows you. It’s not like you’re a name on a chart,” Jacoby
says.
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Doctors running these medical homes generally receive an extra or
bigger payment from insurers to manage a patient’s health. The
amount varies depending on the plan.
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When it started a medical-home program in 2009, Blue Cross Blue
Shield of Michigan increased office visit reimbursements. The extra
pay amounted to about $7,500 more per doctor annually.
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All told, the insurer spends about $35 million a year to support
patient-centered medical homes that now care for around 2 million
people. In return, it estimates that it saved between $65 million
and $70 million last year alone.
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Growth in hospital admissions and emergency room visits slowed for
patients treated in these medical homes. Electronic prescribing
helped doctors use generic drugs more because they could see lists
of covered medicines and co-payments charged to the
patient.
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The insurer’s annual medical costs are about $9 billion, so the
medical homes offer a relatively small slice of savings. Still, Dr.
Thomas Simmer, the chief medical officer, is encouraged.
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“All of us who are vexed by high health care costs are impatient to
find something that’s really going to be the answer to it,” he
says. “You can’t be impatient. You have to realize you’re talking
about human beings and patients’ health.”
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It takes a heavy dose of patience to transform a practice into a
medical home. The process can take a couple of years and has to be
done while the practice is still functioning.
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“The metaphor we frequently talk about is redesigning the plane
while you’re flying,” said Dr. Bob Graham, a former CEO of the
American Academy of Family Physicians who has helped set up medical
homes.
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Patients must also be willing to work more with their doctor or be
comfortable seeing other members of a care team instead of just the
physician. Primary-care doctors also need to foster cooperation
from specialists who may not receive extra reimbursement to do
so.
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Money is an issue, too. Lynch’s practice, which has 58 family
doctors, spent about $500,000 in 2003 to switch to electronic
medical records, a must for quick and efficient file-sharing with
other providers. The practice has since spent more on upgrades and
training, but Lynch says it recouped the investment in part by
becoming more efficient and eliminating the clerical work those
paper files required.
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Despite the challenges, Simmer and others who work with
patient-centered medical homes expect the concept to
grow.
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“I absolutely expect it to be the norm in primary care because it’s
just plain better primary care,” Simmer says.
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