Your doctor's office soon may become your 'medical home' — for better, cheaper health care

by Pat Shellenbarger | The Grand Rapids Press
http://www.mlive.com

GRAND RAPIDS — Dick Ziomkowski admits he wasn’t doing all that well controlling his diabetes after it was diagnosed a couple of years ago.

He wasn’t monitoring his blood-sugar level the way he was supposed to, wasn’t following a proper diet and didn’t get the exercise that could help him avoid a medical crisis.

“I was in denial,” he said. “It was like, I got diabetes and so what?”

In recent months, Ziomkowski has more actively managed his health, and so has his physician under an experimental program many doctors, insurers and others say could revolutionize the nation’s medical system.

It’s called the patient-centered medical home, an approach advocates say should help rein in costs and improve people’s health.

For Ziomkowski, it means a closer relationship with his doctor and a team of nurses, dietitians and others coordinating his care and reminding him to follow a healthier lifestyle.

The American Academy of Pediatrics first proposed the medical home in 1967. But it has gained new momentum amid a rise in some chronic illnesses, escalating health costs and a concern that the medical community must do something about it.

“The present system is broken,” said Dr. Ken Fawcett, medical director for Primary Care Partners, a physician group owned by Spectrum Health. “We can fix it, or someone else can fix it for us.”

Under the patient-centered medical home, also known as the advanced medical home, the primary-care doctor and staff follow up office visits with phone calls and e-mails to make sure patients are taking their prescriptions and doing whatever is necessary to stay healthy.

Advocates say the medical home should result in fewer specialist referrals, hospital admissions and unnecessary tests and procedures. The primary care doctor coordinates all care to avoid needless duplication.

Primary concerns

One problem: There aren’t enough primary care doctors — family physicians, internists and pediatricians — to meet that goal, a shortage blamed on the relatively low pay.

The current system has a built-in incentive for primary care doctors to see a large number of patients and spend very little time with each. Medicare and commercial insurers pay an average of $60 per office visit and nothing for follow-up.

“You have to push a volume of patients through,” said Dr. David Blair, president of the Advantage Health Physician Network, a group owned by the doctors and Saint Mary’s Health Care. “Often it conflicts with being thorough.”

Studies have shown that where the ratio of primary care physicians is higher, patients tend to be healthier and medical costs lower

“The reality today is patients coming into Grand Rapids have a lot of trouble getting into a primary care office,” said Dr. Jim Byrne, chief medical officer at Priority Health, the insurer owned by Spectrum Health, “and the primary care physicians we have are overworked.”

Advantage Health is closing its Cascade Township office, because it cannot recruit enough primary care doctors, said Blair, an outspoken advocate for the medical home.

‘Enormous change’

Fawcett said Primary Care Partners is facing the same problem. Many new doctors who choose primary care are unwilling to work the long hours of their predecessors, he said, so even if the group could replace every retiring physician, it still will face a shortage.

The medical home is “an enormous change,” Fawcett said. “Some physicians are really engaged and want to change. Others are less engaged and think this is just today’s fad. Those people are missing the boat.”

Metro Health is phasing in aspects of the medical home, said Dr. Frank Belsito, vice president of Metro Enterprises, which includes the 12 outpatient centers. He supports the idea “100 percent,” Belsito said, although he was less certain it will cure all that ails the health care system.

“I’d love to say this is the answer,” he said, “but we don’t know.”

Insurers making move

If the medical home catches on, it will be because of support from several of the nation’s largest employers, including the auto industry, and many medical organizations.

Insurers also are lining up behind the medical home, figuring if they pay more to primary care doctors, they can avoid higher expenses later. Some insurers are setting goals for participating physicians, rewarding them with quarterly payments.

Medicare and Medicaid also have initiated pilot programs. Last month, Congress overrode President Bush’s veto of $100 million over three years so Medicare could increase primary-care payments.

Blue Cross Blue Shield of Michigan plans to spend $30 million this year encouraging primary care doctors to expand their services.

“We’re committed to the patient-centered medical home,” said Dr. Thomas Simmer, chief medical officer for the Michigan Blues. “I believe it has a very large chance of occurring on a large scale, because this is what the patients want of their doctors, and it’s the way doctors want to practice.”

Priority Health last month awarded $500,000 to four physician groups to help them move toward the medical home.

Getting there will require additional staffing, more flexible hours and a large investment in computerized medical records, allowing doctors to order prescriptions electronically and alerting them when it’s time for a patient to come in for tests. Eventually, doctors should be able to hold virtual appointments with patients over the Internet, advocates say.

Taking to the pilot

Advantage Health is starting a pilot program, phasing in aspects of the medical home at three offices and eventually all 20. Each patient will leave the office with a detailed plan setting specific goals, Blair said.

“One of the things we’ll do is two days after an appointment, we’ll call the patient and say, ‘Have you filled those prescriptions?'” he said. “We need to call them two weeks later and find out if they’re still on the medications.”

As part of the pilot program, several diabetic patients of Dr. Fred Reyelts gather every three months in the Advantage Health office at 933 Three Mile Road NW. A dietitian, nurse/educator, pharmacist or other provider addresses the group while Reyelts reviews each patient’s file, then meets with them individually to set goals.

Since he began attending, Dick Ziomkowski has monitored his blood sugar twice a day, eaten healthier and ridden a stationary bike every morning. Talking with other patients helped him realize he is not alone in dealing with diabetes.

“It’s controlled better now,” he said. “I have better knowledge now. It works out for me.”

Blair said he is confident the pilot program will prove the medical home is a better than the current system, which is too disorganized, inefficient and difficult for most patients to navigate.

“Absolutely it’s happening,” he said. “This is a crisis. The system is crumbling. We simply cannot afford to go the direction we are going.”

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