Costs are soaring, so many experts say the solution is to turn financial incentives upside down
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Another program that Hawaii might emulate is Community Care of North Carolina. CCNC began as a way to use the PCMH model to deal with the poor, disjointed care system for Medicare recipients in largely rural North Carolina. Over time, CCNC has grown to 646 Medicare demonstration projects in 22 counties. It also includes three federally funded Beacon Communities, and a seven-county, multi-payer primary care demonstration that includes Medicare, Medicaid, Blue Cross Blue Shield and the North Carolina Employees Health Plan. CCNC now encompasses 4,000 healthcare providers and more than a million patients.
In just three years, the North Carolina program appears to have paid off, even though the number of Medicare recipients in the program has increased by more than a million. An assessment by Treo Solutions Inc., a healthcare information services company, found that the state avoided more than $650 million in costs in 2009 alone because of CCNC. This December, a study by the healthcare actuarial firm Milliman showed nearly $1 billion in annual savings. Clearly, it’s numbers like this that are getting the attention of HMSA and the Hawaii healthcare establishment.
A recent study estimated the shortage of physicians in Hawaii at 20 percent, or 644 doctors, and many doctors fear that current trends in healthcare will exacerbate that shortage. Even so, the PCMH concept receives a lot of support in the healthcare community, particularly among primary care physicians like pediatricians, family doctors and internists. It’s not only because of the extra income; many physicians support PCMH because of the increased care it allows them to give their patients and the renewed focus on evidence-based medicine. They’re particularly enthusiastic about HBI Online.
Dr. Brijit “Brit” Reis, a pediatrician with the Castle Health Group, a Kailua-based PCMH, explains the value of the program: “Physicians, and I’ll speak for myself as well, we always think we’re doing a good job. HBI Online is something that we can log into and look at all our HMSA/Quest patients to see whether those patients are up-to-date or not. Who still requires services and what those services are? That’s been great. Now, instead of just saying we’re doing a good job, we can actually look at data and see.”
But she notes that quality controls aren’t all there is to a medical home. “A PCMH is truly a team,” she says. “Care in your office is team-based, and you work at it from a partnership with patients and their families. You figure out what are their barriers to care. Then help them get the care they need. In other words, it’s a little more holistic approach to the patient. It involves the patient more in the process.”
One example, Reis says, is providing after-hours care. “If you’re only open nine to four everyday, patients don’t get in because they’re working, so you’re not really providing for their care.” She says a lot of the PCMH is just practicing good medicine. “It looks at things like do you communicate well with specialists? Do you have a good system for tracking if your patients actually visited the specialist? Did you get back information after they went to see them? If not, why? Maybe they lost the phone number. Maybe the doctor said they wouldn’t see them. But part of good care is tracking your specialist referrals. Do you have a system for looking at all these things?”
It’s also how the team works together to coordinate care and “communication within the staff,” Reis says. “It’s holding daily huddles to see who’s on the schedule today. Is there anything that needs following up on? It’s basic communication stuff, but it doesn’t always happen. And basic communication can be the difference between patients getting the care they need and not getting it.”
Not surprisingly, specialists are among the most skeptical about the PCMH and HMSA’s new reimbursement policies. For some, like orthopedic surgeon Linda Rasmussen, the criticism stems partly from skepticism about a system that has steadily eroded doctors’ earnings. “I’ve been here almost 18 years,” Rasmussen says, “and every year my income goes down. When you look at what I make compared to how many hours I work, it’s like $28 an hour. My sister is a nurse; she makes $36 an hour.” She adds that it doesn’t get any better when you look at it by procedure. “I used to get $4,000 for putting in a new hip. Now, I get $1,400.”
Rasumssen also doubts the practicability of the new system. She points out that many of the qualitative measures used in primary care simply don’t work in some specialties. “Nationally, we’ve been trying to come up with quality measures. But even HMSA has agreed that, with orthopedics, there’s nothing to come up with.”
Rasmussen offers some examples of how specialists could game the system: Physicians could cherry-pick patients, choosing not to serve groups, like the morbidly obese, that could lower their quality-care ratings. Similarly, specialists could foist some services onto the primary care physician, such as a doctor who refuses to prescribe simple painkillers like Motrin or Advil. “He made them go back to their primary care doctor. He got a $2,000 bonus because he didn’t prescribe any drugs, but really he just didn’t want the liability. It’s this game, and you get tired of playing the game.”
Rasmussen also isn’t sure that focusing on primary care will render the savings that healthcare professionals expect. “Primary care doctors will just have to run more tests, which will drive up costs. I don’t need an MRI to tell me your ligament is torn. I can tell on exam. After all, that’s all I do all day.”
The focus on quality controls also doesn’t address malpractice law, which she sees as a major driver of healthcare costs. “I don’t see a lot of waste going on,” she says. “When I look at things, the waste that I see is doing things to avoid malpractice lawsuits.” She notes that she once got sued for failing to perform an MRI even though the insurance company denied coverage for an MRI. “So, do I get an MRI on everyone now, just to avoid a lawsuit in the future? … In this country, the cost of defensive medicine has reached $86 billion.”
To Rasmussen, PCMH isn’t all that different from the failed managed-care model of an earlier generation. “It’s the soup du jour,” she says. “But it won’t work.”
Is it inevitable?
Even PCMH’s most ardent supporters, like Josh Green, acknowledge that changes in the healthcare system pose challenges for many doctors, particularly those in solo or small practices. “The jury’s still out on whether or not this is sustainable for small practices, especially solo practices,” Green says. “Maybe they’ll band together a little more. For example, if they have to provide after-hours care, maybe two or three practices, though they won’t actually merge, will agree to partner up on that particular issue, and all their patients will have access to the service.”
But the trends in healthcare seem inescapable: a growing emphasis on team care, increased use of data to manage care, and the growing prevalence of preventive medicine.
“Small practices can’t survive unless they evolve, because overhead has gotten too large,” Green says. “Part of the evolution for small practices has to be something like PCMH, which brings them more resources.”
Many of the main ideas embodied in PCMH and the HMSA’s new programs are gradually being codified into law. Green points out, “The idea to move more resources into primary care and preventive care is essentially what the Affordable Care Act – Obamacare – is all about. It’s 2,800 pages of different tricks and nuances and pilot programs all built around putting more money into primary care so we can prevent hypertension from getting out of control, and prevent diabetes from getting out of control, and make sure people take their medication properly. Ultimately, PCMH kind of mirrors that.”
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