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Statewide Medical Home Programs Launched in Rhode Island and North Dakota

Patient-Centered Medical Home (PCMH) is the latest concept in managed care. Primary care physicians, relegated to gatekeeper status in the HMO model of the 1990s, are elevated to the status of healthcare guru, taking the role of coordinating care, counseling, and educating patients. Launching the first statewide Patient-Centered Medical Home (PCMH), programs are Rhode Island and North Dakota.

The PCMH concept, which has been endorsed by the AMA, is a care delivery model that provides patients continuous access to a personal physician for the majority of their healthcare needs. There are 22 medical home pilots underway throughout the nation, but Rhode Island and North Dakota are first to take the concept statewide.

The leading advocate for the PCMH is the Patient Centered Primary Care Collaborative, a 200-member group that includes major employers, consumer groups, labor unions and healthcare providers and payers. It contends this healthcare model could improve the health of patients, while ensuring viability of the healthcare delivery system through reduced costs associated with shorter hospital stays, fewer hospital readmissions, and emergency department visits.

A statewide pilot of the Rhode Island Chronic Care Sustainability Initiative was launched last October on the heals of a 2004 state law mandating that health plans work to improve accountability in healthcare affordability, accessibility and quality. The pilot includes the state’s three biggest health plans, including the state’s Medicaid plan, Neighborhood Health Plan of Rhode Island’s Rhody Health Partners; Blue Cross and Blue Shield; and United Healthcare. These plans will pay the five participating primary care practices a fee of $3 per member, per month to cover the services of a care-management nurse.

Rhode Island insurers are optimistic about the model’s potential for reducing healthcare costs and improving outcomes. They also suggest that the new care model, which provides compensation for extra time spent caring for patients, will improve physician satisfaction. Not only with this be due to increased reimbursement, but also because the physicians will have the ability to provide consistent care across the board, regardless of the patient’s health plan.

North Dakota has already completed a two-year pilot of its MediQHome Quality Project, a PCMH pilot focused on diabetes care. The pilot demonstrated an estimated $102,000 savings in the care provided to 192 diabetes patients. The state launched its full-fledged, statewide PCMH program on January 1, 2009.

Under the North Dakota program, Blue Cross Blue Shield of North Dakota, the state’s largest health plan, has agreed to pay primary care physicians a semiannual $50 care-management fee for Blues members treated for coronary artery disease, diabetes or hypertension. However, according to a report from Modern Healthcare,  Jon Rice, North Dakota Blues CEO/senior vice president, questions the need for a “medical home infrastructure” to achieve better outcomes and cost savings. He points out that the pilot focused on a single health issue, but has yet to prove its mettle as a broad-based quality improvement program.

This mirrors the position of TransforMed, a nonprofit subsidiary of the American Academy of Family Physicians that is concerned with creating a financially sustainable healthcare model through a nationwide medical home system. TransforMed urges that an effective medical home program must address all patients in a primary care practice, not just certain diseases.

If there is a downside to the medical home trend, it is that it adds to the workload for doctors, even as the pool of primary care physicians dwindles. Practicing primary care physicians are leaving the field to enter higher-paying specialties. Fewer medical school students are opting to enter primary care.

Dark Daily expects that one consequence of the medical home movement will be for physicians to shift their lab test utilization patterns toward greater use of predictive testing and risk assessment testing. That’s because a major goal of the medical home arrangement is to encourage early diagnosis and active intervention to help the patient maintain optimal health.

Related Information:
The Dangers of the Decrease In Primary Care Physicians

Reducing Hospital Readmission: How Hospitals and Insurers are Making Strides

After discharge, almost one in six patients land back in the hospital due to complications that could have been prevented with better follow-up care! According to the Institute for Healthcare Improvement (IHI), nearly 18% of Medicare patients admitted to a hospital are readmitted within 30 days of discharge, accounting for $15 billion in spending, according to the Medicare Payment Advisory Commission Now, regulators, insurers, employers, and quality-measurement groups are all considering methods to tie hospitals’ payment to lower readmission rates.

“The experience of multiple hospitalizations can take a devastating toll on the human psyche and the quality of life for patients and their caregivers,” said Mary Naylor, a professor at the University of Pennsylvania School of Nursing. There are about 5 million readmissions a year in U.S. hospitals, with approximately a third occurring within 90 days of discharge. IHI research suggests that transitional care programs, which follow patients for varying periods of time at home, reduce admissions by up to 46%.

IHI is working with hospitals to reduce readmissions by: 1) identifying patients at risk for return; 2) scheduling follow-up doctor’s appointments before patients are discharged; 3) sending nurses to patients’ homes within a few days of discharge; 4) monitoring patients at home; and, 5) educating patients and families on how to adhere to medication schedules and self-care regimens. Part of the problem in getting hospitals to adopt these types of discharge programs in the past was that hospitals did not get paid to coordinate care after a patient left. That’s rapidly changing, now that large managed-care groups and insurers are experimenting with programs to cover such services.

Both Aetna and Kaiser Permanente unveiled pilot programs this year that focus on congestive heart failure patients, a third of which are generally readmitted within 30 days of discharge with complications from the condition. Early results from Kaiser’s program suggest success. Its two medical centers involved in the pilot program decreased their hospitalization and readmission rates for heart failure patients to about a third of Kaiser’s system-wide average.

A similar program developed at St. Luke’s Hospital in Cedar Rapids, Iowa, cut unplanned readmission rates in half, to 6%, as of last January. Prior to discharge, patients at St. Luke’s were asked to restate in their own words what they had been told about how to follow care instructions at home. These patients were then sent home with a refrigerator magnet that included a list of symptoms for which they should watch and an emergency number to call.

This emphasis on reducing readmission rates is no surprise to clients and regular readers of Dark Daily. The American healthcare system is actively looking to reduce medical errors, increase health outcomes, and at the same time cut the cost of care. Putting hospital readmission rates on the radar screen is consistent with this healthcare trend.

Further, the pay-for-performance dynamic makes sense. As the health insurer sees a reduction in costs because of a falling rate of hospital readmissions, it can pass these savings along to those hospitals in the form of pay-for-performance incentives or similar reimbursement arrangements. For the laboratory industry, the emphasis on reducing hospital readmission rates is a reminder that eventually pay-for-performance arrangements will arrive at the doorstep of laboratory medicine. Laboratories should be establishing internal performance measurements so they are prepared to document how their quality and efficiency improves over time.

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