A first-in-the-nation experiment started locally in 2008 to improve patient care and at the same time lower health costs has born substantial fruit, new data by Independence Blue Cross show.
In the experiment, the major insurers in one market came together and agreed to pay 32 primary care practices more money. In return, the insurers expected doctors to transform how they cared for patients, adding services and accountability.
The physicians - trapped on a hamster wheel of high volume office visits and often unhappy - embraced the experimental model, and now, in its fifth year, they believe in it strongly, though some question whether doctors will get a sufficient share of the savings to compensate them for all the additional work and expense.
Independence found the medical home model so promising, it expanded. Now, one-third of primary care doctors in Southeastern Pennsylvania who accept Blue Cross are in certified medical homes - 1,400 physicians serving 450,000 members, says the insurer.
And after comparing 125,000 patients in 160 medical homes with patients in traditional practices, Independence reported this week that diabetics in medical homes had 21 percent lower overall costs, including a 44 percent reduction in hospital costs.
Independence didn't release actual dollar amounts, but said savings came from fewer hospital readmissions, and emergency room visits for diabetics were down 34 percent in medical homes.
Independence also said it found cost reductions for its members with chronic conditions such as coronary artery disease, congestive heart failure, chronic obstructive pulmonary disease, asthma, and hypertension.
"This is a better way to practice medicine," said Richard Snyder, Independence chief medical officer, "more satisfying for the physicians and the patients, obviously better clinical outcomes, and we've gotten the first evidence" that it saves money.
For instance, when the experiment began in 2008, Snyder said, fully one-third of diabetics were found to have poor disease management - no regular eye or foot exams, insulin levels not monitored - and by 2012, that dropped to 18 percent.
"If this trends down 1 or 2 percent a year [in a traditional practice] we're high-fiving each other," said Snyder, "and in medical homes these guys are trending to where we've literally had a 60 percent improvement."
Cholesterol control went from 35 percent to 60 percent," he said. "If you look at the rest of the docs, not nearly as impressive."
Richard Baron was a Mount Airy primary care physician who was involved with the experiment when it started in 2008, and then worked in the Obama administration to create a model so the medical home could be replicated nationally. He is now president of the American Board of Internal Medicine. When told of Independence's findings, he replied:
"It's the holy grail of American health care - how do we make health care better and save money at the same time.
"That's why the Pennsylvania model is so important."
Instead of treating the patients seated before them - and getting paid purely on the volume of patients they see - doctors in medical homes focus on managing the health of their entire practice populations, and closely monitoring the sickest patients.
With extra funds from the insurers, doctors hire more staff, including nurses and nurse practitioners to do education, outreach, and case management.
At Jefferson Family Medicine, for instance, every patient who leaves the hospital is called within 48 hours and visited by a nurse within five days.
In the medical home, the doctor becomes one of a team, and all of its members practice to the full extent of their license. A diabetic might get half an hour of instruction from a nurse. Tests and screenings are done in the office, and specialist appointments are made before the patient leaves. Doctors concentrate on the sickest and most complex cases, spending more time with each patient.
With the use of electronic medical records, another staple of the medical home, staff can see which patients haven't been screened, or had poor test results, and monitor everyone much more aggressively.
For the most complex cases, in the best medical homes, a psychologist and pharmacist are in the primary care office, working with other team members.
"As a family physician," said Bill Warning, with the Crozer-Keystone Center for Family Health at Springfield, "I really believe in this model of care. This is the one-stop shopping where the patient can have almost all services attended to or cared for in one place."
Warning said his patients fall into three categories: those who understand the changes and love them; those who are generally healthy, and may not even notice there's been a change; and those who say to the staff, 'Why are you bothering me so much?' "
Warning says he tells patients in that group: " 'It might feel like bothering but it's our way of showing we love you. It's called quality of care and good medicine.' "
In medical homes, practices must improve the quality measures of their overall populations. For instance, how many of a practice's diabetics have blood pressure of 140 over 90 or lower?
"Before medical home activity," said Richard Wender, chair of family and community medicine at Thomas Jefferson University Hospital, "we assumed we were doing a good job, but we weren't measuring and we weren't being held accountable.
"Today," he added, "we are reporting on 15 to 20 quality measures by doc, as well as by practice. But with that comes a lot of pain."
"You realize you're never doing as good a job as you think you were."
Warning and Wender believe everyone is winning - doctor, patient, and payers. The doctors said they would never want to go back to the old way of practicing, but the model is still far from perfect.
Though more satisfying, it can be much more work for doctors. And the extra payments still aren't enough, Wender said.
If a physician wants to become a medical home, Independence begins paying $3 per patient per month when the doctor gets certification from the National Committee for Quality Assurance. If the patient population reaches certain quality measurements, the doctor is eligible for incentive payments. And finally, if there is any savings, doctors and the insurer divide it.
Last year Medicare joined the experiment involving the original 32 practices and is now paying them along with Independence, Aetna, and Keystone First. The payers wanted six months after the end of 2012 to process all claims and compute any shared savings - so doctors have been waiting for 18 months and wondering how much it will be.
This delay is a challenge for many who must extend lines of credit.
Joseph Mambu, a geriatrician in Lower Gwynedd whose practice is among the original 32, and who was enthusiastic at the outset, fears if the payment is insufficient, the model, which he loves, "will die on the vine."
"We have not gotten off the treadmill," adds Wender, who agrees with Mambu that doctors need more money from the payers to make the model a true success. "These blended payment models we're in are a huge step in the right direction. But you know what? They're not sufficient."
Marcela Diaz Myers, director of the Chronic Care Initiative, the 2008 experiment, for the state's health department, said she understood the pressure put on doctors by the delayed payment, and the apprehension over its size. But she said she'd heard from other doctors that payments so far have been adequate.
"I'm not telling you it's easy," she said, "but I'm telling you it's achievable."
Contact Michael Vitez at mvitez@phillynews.com or 215-854-5639. On Twitter @michaelvitez.
0 comments:
Post a Comment