Trying a new approach to primary care: prevention

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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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