Larry Rahn had never heard of a "patient-centered medical home," though his doctor's practice here is one of a handful certified in Kansas.
Nonetheless, the 49-year-old John Deere mechanic said he had noticed something different about Dr. Jerad Widman's approach to medicine and that his health has improved in seven years under Widman's care.
"He goes the extra mile. He's been working on my bad cholesterol for two years and finally has it where he wants it," Rahn said. "He kept hammering on trying to eat right. After a couple years, I finally paid attention. You actually do feel better."
For Widman, the patient-centered medical home approach is about "proactively taking care of the whole patient, not just their chief complaint," he said.
"When people are sick enough to actually come into the doctor, the great majority of the time there's more than just a cold going on," he said. "Patients present with complaints. But most patients don't even know what all needs to be managed. If we leave it to them to tell us what to take care of, we don't take care of enough."
Widman said electronic health records are essential to the way he runs his practice, which is certified by the National Committee for Quality Assurance at Level 3, the highest level.
He said having and maintaining an electronic health record for each patient is the foundation of coordinated care.
He also uses the system to track and organize the care his patients receive outside his practice, which helps him minimize redundant treatments. The digital records also help his staff prepare for patient visits and deliver care at "the top level of their training," he said.
For example, his aides can perform a routine foot exam on a diabetic patient or update a patient's vaccinations even though the appointment initially was scheduled to check blood pressure — all before the doctor enters the exam room.
Proponents of patient-centered medical homes say that coordinating care through a single primary care provider will improve patient health and efficiency of delivery and reduce costs systemwide. Better management of chronic diseases and other preventive care will lead to fewer costly hospitalizations, they say.
Among medical home proponents are officials in the administration of Gov. Sam Brownback. They've indicated that medical homes will be central to their plan to overhaul Medicaid.
If every American had access to a medical home, national health care spending would drop by 5.5 percent, or $67 billion per year, according to estimates by the American Academy of Family Physicians.
Widman said he had no doubt medical homes would yield significant savings as more providers adopt the concept. But so far, he said, there is very little financial incentive for doctors to do so. Doctors make more money the more patients they see — and less money if they spend more time with each patient, he said.
"My only incentive has been top-notch, quality care for my patients. It has actually been to my financial detriment to do it," Widman said. "It's easily cut my take-home pay by 25 percent. That would be a conservative estimate."
As long as doctors are primarily paid for services — not outcomes — Widman said he doesn't foresee the medical home concept catching on.
"My hope is that the reimbursement structure is going to change to incentivize the comprehensive approach as opposed to the volume approach," he said.<a name="TransforMED"></a>
A three-year pilot project under way in Kansas ultimately may lead to the state's largest private insurer changing its reimbursement structure.
The Patient Centered Medical Home Initiative — launched last summer by a coalition of the state's leading medical societies with underwriting from three Kansas health foundations — is intended to help eight practices overhaul their offices into certified medical homes.
• American Medical Practice/Augusta Family Practice, Winfield
• Cheyenne County Clinic and Hospital, St. Francis
• Ellsworth County Medical Center and Rural Health Clinics, Ellsworth
• Mindi Garner, D.O., Pittsburg
• Sabetha Family Practice, Sabetha
• Internal Medicine Group, Lawrence
• KU Wichita Adult Medicine, Wichita
• Plainville Medical Clinic, Plainville
More information about the initiative at Kansas Academy of Family Physicians website.
The practices are working with web-based TransforMED to complete "mini-quality-improvement projects" with the goal of becoming certified at the top level, said Carolyn Gaughan, executive director of the Kansas Academy of Family Physicians.
TransforMED is a subsidiary of the American Academy of Family Physicians devoted to helping doctors get their practices certified as medical homes.
Getting a practice certified as a medical home is not easy, Gaughan said.
"They can't just close the practice and become a patient-centered medical home — that isn't how it works," Gaughan said. "It's stressful, and they're pretty brave to be dedicated to doing this. They're the laboratory in Kansas."
As part of the project, Blue Cross Blue Shield of Kansas is paying the eight pilot practices for implementing various patient-centered medical home practices.
Blue Cross spokeswoman Mary Beth Chambers said data gathered during and after the project would help guide how the company reimburses health care providers in the future.
"We feel fairly confident that there needs to be a move away from the fee-for-service model if we're going to — as a state — get control of health care costs," Chambers said. "The purpose of the pilot is to see whether this sort of model will provide better coordinated quality care that will ultimately lower the cost of health care. If you put more emphasis on the front-end care, prevention and wellness, does that save money over time?"
Last month, Blue Cross affiliate Wellpoint Inc. announced it would begin raising reimbursements for primary care providers who implement certain medical home practices, and even more for those who demonstrate savings. Most qualifying providers in the 14 states Wellpoint serves will see a 10 percent payment increase, and some could earn up to 50 percent more.
Chambers said that while there is a good deal of sharing data and best practices amongst members of the Blue Cross and Blue Shield Association, she could not say how Wellpoint’s move might affect Blue Cross of Kansas’ planning.
“Ultimately it’s up to each independent Blue plan to make the decisions that are best for their service area,” she said.
Verdict is out
Tina Davis is the director of four rural health clinics that — along with the county hospital — comprise the Ellsworth County Medical Center, one of the eight pilot sites.
She said "the verdict is out" on whether medical homes will lower the overall cost of health care.
"If we do our job well, it will reduce the number of in-patient stays and ER (emergency room) visits, so obviously our revenue from the hospital side will decrease. But on the outpatient side, because we're doing a better job maintaining those patients ... our revenue should be greater," Davis said.
Dr. Jennifer Brull's practice in Plainville is another pilot site. She said she's working toward medical home certification solely to improve patient care. But she said the bottom-line benefit of doing so is a question of when, not if.
"I think that people who are smart are going to say, 'I see it coming' — I see more money coming from (operating a patient-centered medical home) and I'm going to jump on that. But you got to have faith so you can be there when the money comes. Otherwise you're going to be playing catch-up," Brull said. "Blue Cross is putting their money where their mouth is; they are actually trying to pay to improve care."
KanCare and medical homes
Using medical or health homes to coordinate care and ultimately lower costs is part of Gov. Sam Brownback's Medicaid makeover, called KanCare. At the Feb. 3 announcement of KanCare's executive reorganization order, cabinet member Shawn Sullivan said health homes were a major component of the plan to move all those on Medicaid into managed care.
"There's going to be health homes within the first two years of KanCare to help coordinate the different parts," said Sullivan, secretary of the Department on Aging, which under the reorganization would become the Department for Aging and Disability Services.
"We've said (managed care companies) can't cut rates, they can't cut the scope of benefits, they can't cut providers. So the way they're going to make their profit is by coordinating the care," Sullivan said.
Brownback administration spokeswoman Sherriene Jones-Sontag said “health home” is a more expansive term than “medical home.”
“Health homes involve teams that have the capacity for a whole-person, integrated approach to care that identifies clinical and non-clinical services and supports for each individual, and coordinates and provides access to all such care,” she wrote in an email. “Kansas' preferred model is a team of professionals, including physicians and other professionals such as nurses, nutritionists, social workers, behavioral health professionals, and any others needed for the appropriate health home.”
Marcia Nielsen said she was skeptical of the Brownback administration's plan as it is currently laid out. Full details of the administration’s plan have not yet been presented to or approved by federal health officials.
Nielsen, former executive director at the Kansas Health Policy Authority, is executive director of the Patient-Centered Primary Care Collaborative in Washington, D.C.
She said the administration's plan lacks a strong, clinician-oriented approach to patient-centered care.
"The plan is ‘Just let the vendors figure it out,’" said Nielsen, who has served on the TransforMED board. "But where transformation happens is in an actual physician's practice. Unless you have the docs at the table owning this process, this is nothing other than the managed care that we tried in the '90s, which was driven by health plans, not by providers and patients.
In 2008, while Nielsen was at the Health Policy Authority, Kansas passed a law that broadly defined a “medical home”:
“A health care delivery model in which a patient establishes an ongoing relationship with a physician or other personal care provider in a physician-directed team, to provide comprehensive, accessible and continuous evidence-based primary and preventive care, and to coordinate the patient’s health care needs across the health care system in order to improve quality and health outcomes in a cost effective manner.” (See page 26 of Sub. SB 81)
The state has yet to draft or adopt specific standards for a medical home. But in an attachment to the KanCare request for proposal, the administration cites a guidance letter from the Centers for Medicare and Medicaid Services on ways to implement health homes in conformance with the Affordable Care Act.
Medicaid RFP attachment I
CMS guidance letter
The attachment also includes a chart that illustrates the linkages the managed care companies are expected to have with a variety of care providers that could serve as health homes. Among those providers are nursing homes, safety net clinics, mental health centers and others.
Jones-Sontag also said the state's health home expectations would be emphasized as the companies' plans are being reviewed or negotiated.
"As with all sections of the bid responses," she said in an email, "the state will review and, if necessary, suggest changes before approving health home models submitted by bidders to ensure they meet the state's policy objectives."
North Carolina is a state cited by Brownback officials for demonstrating savings with medical homes. It crafted its own guidelines for Medicaid providers.
Nielsen said the entire nation is in the early stages of medical home certification, but even with that Kansas providers are lagging their counterparts in other states.
She said certification was crucial because otherwise any medical provider could claim to have or be a medical home.
"At the end of the day, everybody's going to have to have some kind of certification. Otherwise everyone will just say they are a patient-centered medical home," Nielsen said, "when in reality very few are."
Patient-centered medical homes are among the models for reducing health care system costs explored in a new documentary, "U.S. Health Care: The Good News." It began airing last week on local PBS affiliates.
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