Imagine a world where a primary care physician’s typical day involves seeing 10 patients, the chronically ill that really need his expertise, while physicians’ assistants and nurse practitioners handle people with colds or mundane complaints.
It’s a world where follow-up care takes place over the Internet, through secure e-visits, or through phone consults. It’s a world where physician income isn’t tied to patient volume, where a primary care doctor’s day ends at 5 p.m.; where he has more time with his family, and a life outside the clinic.
Imagine a world with healthier, more satisfied patients and staff. Now imagine that the physician makes more money than he does under the current system.
That’s the world that Blue Cross and Blue Shield of Louisiana officials hope to make a reality through the patient-centered medical home model. Blue Cross is offering the healthcare plan in the New Orleans and Baton Rouge areas through subsidiary HMO Louisiana Inc. The insurer is working with Ochsner Health System and Baton Rouge General Physicians to implement the new models.
Dr. Ken Phenow, Blue Cross chief medical officer, said the concept removes “the perverse” incentives in the fee-for-service model, which consumes lots of care with little regard for cost.
“Under the medical home, a primary care physician quarterbacks a team of folks, a nurse practitioner, a physician’s assistant, dietitian, nutritionist …. He can distribute patients based on acuity and the level of knowledge needed to care for them,” Phenow said.
That leaves the physician free to tackle the more difficult patients, those with multiple chronic conditions such as diabetes and hypertension, Phenow said. The doctor can focus on the sicker patients and slowing the progression of their disease or diseases.
That’s where the real savings occur, in keeping the chronically ill as healthy as possible, according to Phenow. Keeping those patients out of the hospital, or being readmitted to the hospital, and away from the emergency room, sharply reduces costs.
Studies have shown that approximately 56 percent of patients aged 18 to 65 have one or more chronic diseases, and if the over-65 crowd is included, that probably rises to the 70 percent range, Phenow said.
But the current healthcare model isn’t set up to deal with the chronically ill.
A primary care physician gets paid a little more for treating a person with diabetes, hypertension and hypothyroidism – maybe $30 – than for treating a person with a cold, Phenow said. But a doctor can see four or five people with colds in the same amount of time it takes to deal with the chronically ill patient.
“What happens today is that a lot of doctors try to deal with these chronics a couple of times,” Phenow said. “But if they can’t, if they feel this person is kind of difficult for them because it’s hurting their … revenue flow, they turf them out. They consult them away to a specialist, and then it becomes the specialist’s problem.”
The idea behind the medical home is to free up the primary care physicians and give them a different set of incentives, Phenow said. Primary care docs will be paid to focus on the chronic patients.
Those patients cost the healthcare system a lot of money if they end up being treated by specialists, who, because of their training, tend to order a lot more tests, Phenow said.
“The physician in the medical home really has an incentive to keep people healthy. And that’s not really the incentive today,” he said.
The Louisiana State Medical Society supports the concept of medical homes, as long as the models are physician-directed and the doctor remains the primary healthcare provider, Executive Vice President Jeff Williams said in a prepared statement.
“Patients benefit when all of their healthcare providers are on the same page; however, physicians are expertly qualified to make a fuller diagnosis, deal with rare or severe medical issues, prevent potential complications, prescribe more effective medication and perform safer surgeries,” said Williams.
Phenow said the Blue Cross medical home model will provide physicians with the data to help manage patient populations.
The average physician has no idea what’s going on with their patients once they leave the clinic, Phenow said. The doctor doesn’t know whether the patient is filling his prescriptions, following up with a specialist, or going to the emergency room twice a year or 25 times a year.
The fragmentation in today’s healthcare delivery model, the lack of coordination between primary care doctors, specialists and hospitals, allows a lot of people to fall through the cracks, Phenow said. However, armed with the proper information, primary care doctors can start to understand what’s going on with their individual patients, as well as their entire patient population.
Phenow said he is hoping that the medical homes will show results in the first year, blunting a 30-year trend of escalating healthcare costs.
Over time, medical homes could flatten the healthcare cost curve, helping make the system more sustainable, Phenow said, and ending the “ridiculous” rise in healthcare spending without an accompanying improvement in outcomes.
“I’m all for spending money on healthcare if we can get good outcomes,” Phenow said. “But we don’t get good outcomes. We’re ranked really poorly on outcomes relative to the amount of money we spend.”