R.I. health project test of ‘medical home’ concept

The concept of the “medical home” is neither radical nor untested: In some countries, it’s the norm, and some U.S. medical practices function this way as well, at least to some extent.
Each patient has a primary care physician who is the steward of his health, providing preventive care, ensuring he eats well and gets exercise, managing chronic conditions and working with specialists, as needed, to handle more complex issues.
The doctor doesn’t do this alone, but rather as leader of a team that may also include nurses and nurse practitioners, nutritionists, psychologists, social workers – plus support staff. He may share resources with several other doctors, including even some specialists.
They use technology to facilitate it all: electronic medical records, clinical support systems (perhaps tied to the EMR) to ensure they are following the best and latest science, and e-mail as an extra way to communicate with patients – who can get help 24/7, year-round.
The basic concept has been around for decades. Now, a growing contingent of doctors, policymakers, health care industry leaders, even business giants such as IBM, are hoping this modern version will save American health care.
Locally, Quality Partners of Rhode Island and Health Insurance Commissioner Christopher F. Koller are leading a project called the Chronic Care Sustainability Initiative (CSI-RI) – one of four regional initiatives funded by the Center for Health Care Strategies in 2006 – to implement that model of care in conjunction with a payment system that makes it feasible.
Nationally, the Patient-Centered Primary Care Collaborative, a coalition of major employers, consumer groups, primary care doctors’ groups and others, is working to make this concept a reality across the country, also with payers closely involved.
Last month, Dr. Michael Barr, an internist, vice president for practice advocacy and improvement at the American College of Physicians, and an adviser to the CSI initiative, made the case for this new model to an audience of doctors, medical residents and local health care leaders in a “grand rounds” lecture at Rhode Island Hospital.
He began with the financial case: Health care costs are rising too rapidly, already 16.2 percent of the U.S. gross domestic product, and about twice per capita what is spent in Canada and Western European countries, yet access to health care is far more limited here, and our health outcomes are not as good overall.
Barr also noted that current efforts to slow spending growth aren’t working properly – the Medicare Sustainable Growth Rate, for example, is so unrealistic that this year, for example, it called for a 10-percent pay cut for doctors even as their costs continue to rise.
“How do you discourage inappropriate growth in our health system and at the same time encourage appropriate growth?” he asked.
Moreover, Barr said, there’s a growing need for primary care doctors – Medicare figures show, for example, a growing number of patients with five or more health conditions, requiring careful coordination – but fewer and fewer medical residents want to become primary care doctors, and many who do quit within years.
To reverse these trends, the American College of Physicians and other professional groups have turned to the “medical home” model. Last year, the American Academy of Family Physicians issued a list of principles to serve as a starting point:
&#8226 Each patient has a personal physician.
&#8226 The medical practice is physician-directed but team-oriented.
&#8226 The “whole person” is cared for.
&#8226 Care is coordinated and/or integrated (for example, if multiple doctors or a nutritionist or a physical therapist are involved).
&#8226 Quality and safety are paramount.
&#8226 There is enhanced access to care.
&#8226 The payment system is aligned with this model.
The principles became the foundation for the Patient-Centered Primary Care Collaborative, which has gotten strong support from IBM and now involves major health insurers and the employers of 50 million Americans, plus groups representing more than 300,000 doctors.
The coalition recently released more detailed guidelines, with some items listed as “musts” – for example, systematic handling of clinical data, analysis of major conditions affecting patients in your practice, tracking and follow-up with patients – and others, such as adopting EMRs, as desirable but not immediately required.
Now the AAFP and the Commonwealth Fund are working to calculate the cost of implementing such a model, so payment systems can be developed accordingly. And the Centers for Medicare and Medicaid Services will be sponsoring a three-year demonstration of Medicare “medical homes” in up to eight states, starting in 2009, Barr said. &#8226

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