'Medical home' concept embraced by IBM, other employers


When an IBM executive suddenly developed chest pain, he made an appointment with a cardiologist, who performed a battery of tests that had inconclusive results except an unidentifiable abnormality in the neck region.

The cardiologist referred the executive to a neck surgeon, who removed the abnormality. The chest pain, however, persisted.

Several months later, the executive visited an IBM doctor to receive vaccinations prior to traveling overseas and again reported the nagging pain. The company doctor pressed on the executive’s chest, reproduced the pain and asked whether the executive had made any changes in his routine before it started.

“It began when I started weed-whacking,� the executive said.

It turned out the executive was experiencing muscle soreness and inflammation due to overexertion. But the correct diagnosis was not made until after $168,000 had been spent on tests, surgery and several visits to specialists.

If that executive had a “medical home,� a primary care doctor providing comprehensive, holistic care, the cause of his pain may have been identified much earlier, said Dr. Paul Grundy, IBM’s director of health care technology and strategic initiatives.

He said the hallmarks of a “medical home� are an ongoing relationship with a doctor; a team approach to delivering comprehensive, coordinated care that is integrated across the health care system; the use of tools, such as electronic medical records, to ensure that care is delivered safely and prevents redundancy and medical errors; and expanded access, including evening and weekend office hours and the use of e-mail and telephone consultations (see story, page 10).

While in some ways the medical home sounds like the primary care physician in a closed-network health maintenance organization, the medical home does not serve as a gatekeeper but rather as a gateway to the health care system, Dr. Grundy said.

“A medical home is a real and virtual relationship with a doctor centered around a patient’s needs,� he said.

Primary care system broken

IBM was one of the founders of the Patient-Centered Primary Care Collaborative, a coalition of large employers and employer groups, consumer organizations and medical providers dedicated to promoting the medical home concept to improve the quality of care and hopefully lower its cost.

“It started about three years ago with a discussion around my boss’ swimming pool,� Dr. Grundy recounted. “We were talking about the things large employers had done (to control health care costs and improve quality) and realized that we were not addressing the fundamental issue…that the primary care system is broken.�

After that discussion, Dr. Grundy said IBM approached its health plans, asking to buy comprehensive care for its employees, but the plans said they couldn’t do that.

“They said they could only sell what Medicare allows: episodic care based on code numbers,� Dr. Grundy said.

For example, the current system compensates a surgeon for amputating the gangrenous limb of a diabetic patient, but it doesn’t adequately compensate that patient’s doctor for managing the care to prevent the amputation, Dr. Grundy said.

“So we reached out to primary care physicians and formed an organization that can change the way we pay for care,� he said. “It would make sense for buyers of care to pay more upfront if they get the value on the back end. Companies like ours are committed to doing that.�

Backers of the medical home model all agree that changing the provider compensation system is essential to shifting the focus of medical delivery away from episodic care toward more comprehensive, holistic care.

“There needs to be a re-emphasis on the importance of primary care,� said Dr. Bruce Bagley, medical director for quality improvement at the American Academy of Family Physicians, which is a member of the collaborative. “The thing that’s wrong with the health care system is we value high tech, impersonal care for some vs. primary care for all. This is the antidote.�

Medical homes also could prevent an impending shortage of primary care physicians, Dr. Bagley said.

Will doctors buy in?

Because the payment environment has undervalued primary care for the last decade, “fewer doctors are going into it. This is a way to reshape the payment environment to get a greater proportion of health care dollars to flow to family physicians for these services,� Dr. Bagley said.

It also can help finance advances such as electronic medical records, he added.

“EMR and the medical homes are on parallel tracks,� Dr. Bagley said.

Bridges to Excellence, a coalition of employers devoted to improving the quality of patient care, recently launched the BTE Medical Home Program to reward physicians who demonstrate they have adopted good systems and processes of care and are using those systems to deliver positive results in the management of their patients.

“These doctors will be compensated differently,� said Francois De Brantes, chief executive officer of BTE. “We believe very strongly…that these practices deserve somewhere around $125 per patient per year in some form of additional incentive. How that incentive is distributed is up to each plan or employer. Some plans are focusing more on fee schedule increases; others are paying a basic capitation fee for care coordination.�

In addition to capitation payments, “providers will receive a bonus based on the quality of care they deliver based on a set of standard performance measures,� Mr. De Brantes added.

But it is uncertain at this point whether payments such as the annual $125 per patient stipend BTE provides will be enough to induce primary care doctors to serve as medical homes.

Paul Keckley, executive director of the Center for Health Solutions at Deloitte L.L.P. in Washington, estimates it will cost at least $100,000 annually per practice to fully implement the medical home model, based on a study the center published in February titled “The Medical Home: Disruptive Innovation for a New Primary Care Model.�

To foster a transformation of the medical delivery system to emphasize primary care, the Washington-based National Committee for Quality Assurance recently launched a new version of its Physician Practice Connections program to evaluate medical homes.

The new Patient-Centered Medical Home designation program will emphasize the systematic use of patient-centered, coordinated care management processes, said Margaret O’Kane, NCQA’s president.

“It’s trying to assess whether you’re a 21st century practice,� Ms. O’Kane said. “It’s much more proactive than the old model of just thinking about you when you show up for an office visit. It’s creating an ongoing relationship with the patient.� —Business Insurance

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