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Health Care Model Faces Hurdles On Quality and Cost

Jun 25, 2010

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Physician Scott Eden's primary care practice is a model for the reforms that President Obama is hoping to unleash with the health care legislation he signed this year. Eden's Annapolis, Md., office has added an online medical record system and adopted new procedures to oversee and coordinate his patients' care. That, in turn, has allowed him to shift clerical work and basic patient interactions to new staff he's added.

As a result, he says he now sees three to five more patients each day, and no longer brings home the unreturned phone messages and unfilled prescription orders that had kept him working until 11 p.m. "I can actually do things for patients that I was not able to do," Eden said.

The practice is part of a two-year pilot project funded by insurance giant CareFirst that has helped change its relationships with patients, largely by paying the doctors to provide additional care and examinations that go uncompensated under existing insurance plans. Eden and his partners suspect that their new model has kept patients healthier by actively managing treatment and pushing routine preventive testing, and cut costs by heading off emergency room visits and defensive referrals to specialists.

But this patient-centered experiment in Maryland faces a bumpy road. Once the CareFirst funding runs out at the end of this year, these innovations may not be sustainable. Unless they can get paid for these services, the doctors say they may not be able to continue checking up on a patient's diabetes or inoculations, or visit with patients via e-mail. "I'll do that to a certain extent, but I've got to go see the next patient in the next room to meet overhead," said Patricia Czapp, another doctor in Eden's office. "It all goes away," she said of the extra services.

The U.S. spent $2.5 trillion last year on health care, or nearly 18 percent of the gross domestic product, according to government figures. Health care spending, including the government’s Medicare and Medicaid programs, has consistently grown at a faster pace than the economy as a whole since the 1960s, a major cause of alarm among government leaders attempting to deal with the long-term deficit.

The doctors say they can't adopt a new approach without major changes in the dominant payment structure, in which reimbursements from private insurance and Medicare are based on procedures and not time spent or difficulty of a case. And while there are many more pilot projects under way across the country to streamline and better coordinate medical services, experts say there are few incentives in the new health care overhaul law to promote the Annapolis  model, and not enough research to justify it yet.

"If you want to look at it skeptically, well, this is a way to boost payments to primary care physicians, which intuitively could lead to savings elsewhere in the system, but there is not a lot of strong evidence that the savings are there," said Stephen Zuckerman, a health economist at the Urban Institute, a Washington think tank.

Bending the Curve

During the health care debate, Obama argued that slowing the growth of health care costs depends on steering the industry to adopt more cost-efficient methods such as computerizing medical records, coordinating services and referrals and boosting prevention to cut down on emergency room and prescription drug costs. The law authorizes demonstration projects to test models and see what works.

In the current system, care is often fragmented by medical specialty, paid by procedures, not outcomes, and lacking communication between practitioners. At the same time, everyone agrees that primary care is highly inefficient and ill-prepared to handle the 30 million new patients that will be added to the insurance rolls as a result of the new law. “They spend a lot of their day doing stuff that somebody else ought to be doing that they don’t find particularly rewarding or challenging,” said Paul Grundy, who is head of IBM's health care transformation projects. At the same time, heavy caseloads and relatively low pay have caused a looming shortage of primary-care clinicians—35,000-44,000 by 2025.

So the Annapolis doctors are trying one new model, the "patient-centered medical home," the profession's term for practices that expand communication and access to doctors, manage chronic conditions and adopt a team-based approach to care that includes primary doctors as well as nurses and medical assistants.

At the Annapolis practice, where five primary care doctors manage about 12,500 patients, electronic record-keeping is central to the entire system. Doctors and staff can enter vital signs and notes into tablet PCs, which contain patients' histories, appointments, prescriptions, even digital versions of x-rays. It gives the doctors easy access to information to discuss with patients, and prompts them about prescription refills or preventive tests such as a colonoscopy. (One study found that providers writing electronic prescriptions were seven times less likely to make errors than those doing it by hand.) Patients can see their records and get prompts for appointments and tests through the Internet, so they have access to the same information and can see blood test results, for example, as soon as the doctor does.

Under the old model, the practice, which is owned by Anne Arundel Health System, was productivity-driven, meaning that more patients and more procedures meant more pay. Under that model, Czapp said, she might have had five minutes to deal with a patient's vision problems, chest pain and knee pain—a recipe for multiple referrals to specialists amid a fear of getting sued for missing something. "What am I doing at that point?" she asked. "I'm a waitress. I’m not doing anything." Now, a patient can come in for nearly any kind of care on the day they call—or maybe they correspond via secure e-mail through the record system. The office phones allow emergency access to a doctor 24 hours a day. If someone comes in for a sinus infection but is due for a pap smear, Czapp says she can take care of it on the spot. "You start reacting to patient requests a little differently," she said.

As employers begin to demand more for their money from insurers, CareFirst officials think this approach will save money and promote better health. CareFirst pays the practice a management fee for each of its patients and reimburses for preventive tests, e-visits and other uncovered services.

Robert Morales, a patient of Czapp's, came into the office in February 2009 after a fall with a broken knee and saw the benefits firsthand. Staff quickly pulled up his records, called in a specialist and had him in a cast and on his way within an hour. "When you have an emergency and you go around to a medical center – bingo! You don’t have to fill out all those stupid forms, with the same information every time," said Morales, 73, a retired lawyer who lives in nearby Crofton. He regularly looks at his records online to check appointments and lab results. "I don’t have that kind of relationship with my urologist, who's a first-rate man, but he's not wired this way," he said.

The Jury is Out

Despite the anecdotal evidence, however, substantial data has yet to emerge showing that this model saves money or lives. A two-year nationwide study published earlier this month looked at three dozen practices trying to adopt these changes, but found no evidence of better health, and in some cases found that patients thought their care got worse. The study did not look at cost, nor were the doctors given any financial incentives to change, though some got technical assistance. Terry McGeeney, the head of TransforMED, which funded the nationwide study and is the lead doctors’ group supporting the model, said it was nonetheless helpful to see what works and show the challenges involved. "The project is really set up as a learning map," he said. But the lack of evidence has kept insurers from changing the way they pay, and kept large employers from pushing for it as well, said Zuckerman of the Urban Institute.

The medical community has yet to reach consensus on the best way to manage and pay for the health-home model. While the new health care law favors strengthening building blocks of the system like prevention and care coordination, it doesn't give this model any special consideration. Medicare will now cover some prevention and coordination services. "I think at this point there certainly isn't anything in the bill that would move to widespread adoption of the patient-centered medical home in Medicare or Medicaid," Zuckerman said.

And most primary care is provided by small offices that aren't connected to a larger health system and can't afford a huge change in their practice model. "The biggest impediment is still the independent small practices," said McGeeney. "They are so busy from dawn to dusk, seeing patients, trying to stay afloat, that they're maybe not as engaged in this whole national movement as they should be."

The health-home idea is gaining traction in some places, however, and several trials in specific settings have shown success. One pilot in Pennsylvania showed a 7 percent drop in spending, 20 percent fewer hospital admissions and many practices being able to see more patients. "The bottleneck is really psychosocial," said Grundy, a leading proponent of the medical home model. He believes that the country’s already past the tipping point toward adopting the model on a large scale.

For doctors like Czapp, it would mark a move back toward what she was promised in med school that primary care would be—a close connection and active relationship with patients.

"We were all hot to be doctors like that, but because it was never valued and never affordable, we never got there," she said. “We need to value what primary care is doing to keep somebody out of the hospital, out of the operating room, out of the emergency room," she said. "Until you start recognizing the value of that and reimbursing it, you can’t change this machine, which is specialty-driven, procedure-driven and fragmented."

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