Medicare to do National Demonstration Project Involving Medical Homes
Medical home pilot projects are being closely watched by pathologists and clinical laboratory managers. This is a new model of patient-centered care which has important advocates among primary care practitioners. If the medical home concept catches on, it may require clinical laboratories to provide laboratory testing services in a different way.
In southeastern Pennsylvania, a medical-home pilot project is taking a “do-it-yourself” approach to managing chronic illnesses. This project is viewed by some as a precursor to a national model. The innovative program, which combines the Wagner Chronic Care Model with the patient-centered medical home concept, provides physicians with resources to improve patient–doctor communications. The pilot project is also designed to educate willing patients on how to self-manage their chronic illnesses.
Self-management is a key component in the Chronic Care Model developed by Ed Wagner, founding director of the MacColl Institute for Healthcare Innovation and senior researcher at the Group Health Research Institute in Seattle. This model calls for a proactive, physician-led clinical team to provide safe, timely evidence-based care, as well as clinical information systems that provide decision support and delivery-system design, Eric Larson, executive director of the Institute, explained in an article in Modern Healthcare.
Pilot funds, for example, enabled Greenhouse Internists, a Philadelphia practice with about 9,000 patients, to hire a health educator to train medical assistants in motivational interviewing techniques in support of the patient home concept. These medical assistants help patients design lifestyle action plans with achievable goals. The medical practice also customized its electronic health record (EHR) system to provide patients an action-plan form with sample goals, like medication and diabetic dietary compliance.
“The patient spends one-tenth of 1% of their time in the doctor’s office and the rest of their time on their own, “ noted Richard Baron, M.D., President and CEO of Greenhouse Internists, in the Modern Healthcare article. “Coming up with good ways to engage them and encourage them to take control and make changes is very important.”
This three-year patient home initiative was implemented in 2008 by Governor Ed Rendell’s Chronic Care Commission. It currently focuses on diabetes and pediatric asthma, but will eventually include all chronic conditions. Currently, it involves six payers and 32 physician practices with about 15,000 adult diabetes patients and 12,000 children with asthma.
In remarks at the first annual gathering of the pilot’s pioneers, Governor Rendell noted the program’s preliminary successes. “Your diabetic patients are taking control of their own care: the number with self-management goals has increased 195% in one year since you began the chronic care initiative. There has been a 71% increase in the number of people getting eye exams and142% increase in the number getting annual foot exams,” he added. “The number who lowered their cholesterol below 130 increased by 43% and blood pressure below 140/90 [increased] by 25%. All of these improvements mean healthier Pennsylvanians.
“It is exactly the results we envisioned when we included Dr. Ed Wagner’s chronic care model in the Prescription for Pennsylvania,” Rendell continued. “What’s exciting is that we’ve just started. Just imagine the effect it will have the longer it is used for all chronic diseases and as more regions of the state begin to use it.”
With a growing shortage of primary care physicians, the need for patients to self-manage their conditions will intensify, suggested Baron, who authored a recent article in the New England Journal of Medicine that discussed the overload of uncompensated care activities that overwhelm the capacity of primary care practices.
Supplement payments provided by the pilot for improvements, such as patient self-management, performance reporting, and referral tracking, are expected to increase Greenhouse’s gross revenues 15%. Baron noted, however, that implementing these activities involved a significant investment of time and money. Therefore, he said, “Changes to the payment system are essential, and I am optimistic that these enhanced models of primary care will eventually be paid for. Primary care can be of very high value, but only if it is structured and paid for differently.”
Robert Wachter, M.D., Professor and Chief of Hospital Medicine at University of California San Francisco, told Modern Healthcare reporter Maureen McKinney that pilot projects like the one in Pennsylvania “are essential to show us how successful medical homes can be.” But he emphasized that success in safe, effective patient self-management depends on the provision of incentives for patient education. “The truth is that medical homes will be too expensive for the system, as it is set up now,” he stated. “There has to be a way to capture payment.”
Among patient educators, however, there is growing consensus that self-management education can best be accomplished outside the physician office in community settings, such as senior centers.
Among them is Kate Lorig, Director of the Patient Education Research Center at Stanford University School of Medicine in Palto Alto, Calif. She created a Chronic Disease Self-Management Program that trains and licenses people with chronic conditions to teach classes in self-management in non-clinical settings.
The 15-year-old program now has more than 50,000 graduates throughout the nation and 20 other countries. Lorig said that studies have shown improvements in health outcomes, symptom management, and doctor-patient communication after completion of the program. “The truth is it is not the clinician’s job to help patients with self-management,” she opined. “They [physicians] would like to do it, of course, but they just don’t have the time.”
Currently, there are medical home pilot projects in 22 U.S. states and the concept will soon be nationwide. The Tax Relief and Health Care Act of 2006 mandated that Medicare establish a nationwide demonstration project involving medical homes by the end of this year.
With the medical home model involving large numbers of patients with chronic illnesses, clinical laboratories are likely to experience increase utilization of laboratory tests by physicians. Medical home expansion also will accelerate development of a nationwide electronic healthcare information network (EHIN). Since physicians will order tests and receive results electronically, growth in the medical home concept is one more reason why laboratories should have the technology in place to electronically receive lab test orders and send lab test results digitally.
—P. Kirk
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