Medical homesteading: Moving forward with care coordination
■ With a Medicare medical home project behind schedule, some physician practices have forged ahead without the federal government's help.
At first, the Cranford Family Practice in Cranford, N.J., did not appear to be the most logical choice to be a pioneer of the patient-centered medical home concept. For starters, the single-physician practice did not have a very robust disease registry to track patients across care settings. It also had limited electronic communication with patients, and it did not regularly host group visits for patients with related diseases or illnesses.
But by participating in a national demonstration project with 35 other small- and medium-sized family practices, family physician Robert Eidus, MD, helped his practice realize its potential to serve as a medical home by strengthening its resources.
"For some practices, this was completely new," Dr. Eidus said. "But others had been working in this direction for many years, and this was a catalyst to keep moving in this direction and foster patient care."
The demonstration was sponsored by TransforMED, a wholly owned, for-profit subsidiary of the American Academy of Family Physicians that offers medical home products and consulting services. Similar projects are under way in numerous states involving physician practices of all sizes, employers, insurance companies and state governments. They hope to show that medical homes can improve care and reduce costs by providing patients access to dedicated physician practices that manage and coordinate their care.
The federal government has yet to follow suit. A major Medicare demonstration in eight states that will pay higher rates to selected practices that serve as medical homes was supposed to have started recruiting participants in January 2009. That initiative has now been delayed.
The Centers for Medicare & Medicaid Services cited the arrival of a new administration as one of the main reasons for the holdup. But at this article's deadline, the White House Office of Management and Budget also was taking a closer look at the projected budget for the project. Under the plan, the extra medical home payments per physician could run in the thousands of dollars per month, though CMS officials said they hoped the investment would save money over the long run through reduced hospitalizations and lower medical costs.
Until Medicare has a chance to try out medical homes, physicians exploring the concept will need to look for feedback from physicians who have pursued other avenues. Those on the cutting edge of the medical home concept hope these early pioneers will show how medical homes can work. The lessons for Congress and other policymakers already are coming out.
"One of the problems is that it can be expensive, and it can be impractical for some practices," Dr. Eidus said. "Unless, of course, there are changes to the external reimbursement."
An initial analysis of the TransforMED project's results indicated that medical home implementation "consumes an inordinate amount of time, energy and dollars," according to a report in the May/June Annals of Family Medicine(link).
TransforMED expects to release a final analysis by the end of the year.
The persistent problem of pay
Until the Medicare demonstration launches or lawmakers decide to change the payment system, physicians will not receive one federal dollar more for coordinating their patients' care through a medical home. Many doctors see that as the main barrier. But some private insurers have started putting their own money toward the concept.
David Lainoff, MD, was able to take advantage of such financial help by hiring a nurse to work as a case manager with his diabetic patients. He's an internist and medical director of Crozer Medical Associates in Eddystone and Media, Pa., part of the Crozer-Keystone Health System. Dr. Lainoff's eight-person practice has been one of 32 participants in the Southeast Pennsylvania Collaborative, a three-year medical home program that launched in May 2008. It's part of a comprehensive effort by Pennsylvania Gov. Edward G. Rendell to help control health care costs and involve insurance companies in patient-centered medical home planning.
When the program began, only about 40% of Crozer's diabetic patients had received a recommended foot exam. A year into the program, Dr. Lainoff estimates that the number grew to 90%.
Dr. Lainoff credits the financial involvement of the insurance companies for the success of the collaborative, which Rendell is expanding to the entire state. Six insurers committed to paying the practices up to $13 million over the course of the project to meet certain performance goals.
Other insurers and states have begun to pay for medical homes. Blue Cross Blue Shield of Michigan, for instance, recently said it would spend $60 million in 2009 to help more practices meet the National Committee on Quality Assurance's three-tiered system of patient-centered medical home standards. Community Care of North Carolina coordinates services for nearly 1 million Medicaid beneficiaries across the state. CIGNA HealthCare and the Dartmouth-Hitchcock physician group practice have been conducting a medical home demonstration in New Hampshire for a year.
The American Medical Association sees many potential benefits in paying more for patient-centered medical homes, but it insists that programs not become too restrictive. "In the past, some attempts to change health care have been seen as a gatekeeper process, and no one wants to see the medical home become like that," said Robert M. Wah, MD, an AMA Board of Trustees member.
The AMA also opposes budget-neutral policies for medical homes that take money from other physician services to fund the coordination. Dr. Wah said medical homes instead should be seen as an "elevation of services," requiring additional funding.
Obtaining an electronic medical records system is the first step toward becoming a medical home, and that can take a financial toll at first, said Kim Leatham, MD, an internist and family physician with the Virginia Mason Medical Center, a network of primary and specialty care clinics based in Seattle that is also a part of TransforMED's demonstration. "It's tough being an early adopter."
Dr. Leatham is one of many doctors anxiously waiting for the federal government to get in the game. "Doing it one insurance group at a time is never going to be comprehensive," she said. "Regardless of who pays for it, someone has to lead the way in identifying the system and making it happen. CMS has a lot of research and analysis that can show if it's working, and I think that's what it's going to take."
Some physicians have managed to be medical home early adopters without being paid any more for their services, but those practices appear to be relatively rare.
Speaking before the Senate Health, Education, Labor and Pensions Committee in May, Marsha Raulerson, MD, a pediatrician in Brewton, Ala., noted that the American Academy of Pediatrics first used the term "medical home" in 1967 and published its first statement defining it in 1992. She started practicing in 1981 and has considered her office to be a patient-centered medical home since soon after that time. Still, she testified that most physicians need financial help to adopt health information technology and other required resources.
Return on investment
Despite the money and effort required, some medical home pioneers say they already have gained invaluable experience.
Allan Crimm, MD, is an internist and managing partner of Ninth Street Internal Medicine, a nine-person practice based in Philadelphia that also participates in the Southeast Pennsylvania Collaborative. He feels that the medical home concept must be an integral part of lawmakers' health system reform discussions.
Dr. Crimm's practice did not at first have all of the components of a standard medical home model. And even after they were in place, he realized that a home requires a new way of thinking in addition to new resources.
"We started using an electronic medical record three years ago, and it drastically changed our workflow and tasks," he said. "But we felt like something was missing. We had this new system, but we were basically doing the same thing as before, but just not recording the data with pen and paper. It wasn't changing anything regarding our clinical endeavors. We needed to figure out how to use the tool."
Like some other pioneers, the physicians in Dr. Crimm's practice wandered alone for a while before encountering others with whom they could collaborate. By developing a system of care for patients that involves teaming up with other physicians as well as nurses, care coordinators, consulting pharmacists and social workers, some of these practices are finding their way.
The team approach is essential, Dr. Eidus said. "Otherwise, you have all of this rich data which you cannot act upon."