A concept emphasizing preventive medicine in primary care clinics has gained momentum but needs more support from insurers before it plays a major role in the Midlands.
The concept, called “medical home,” asks doctors to keep their patients healthy and insurers to reward those doctors accordingly. But it also requires upfront costs for the provider, who may have to expand staff and improve computer technology. To date, insurance companies' participation has been spotty.
Alegent Health Clinic's Dr. William Lowndes called it a “mind shift” in how doctors approach their practices and how payers compensate them. Alegent has eight sites working with Blue Cross Blue Shield of Nebraska to act as medical home clinics, Lowndes said, and more will adopt the model soon.
Blue Cross in 2010 and 2011 oversaw a project involving 1,243 diabetics treated by medical home clinics in nine Nebraska communities. The insurer found the medical homes helped patients improve their blood pressure, diminish their bad cholesterol and lower blood-sugar levels.
The diabetics in medical home clinics had 27 percent fewer emergency room visits and 10 percent fewer hospitalizations, the firm reported.
“I have no doubt that the medical home is better for the patient,” said Dr. David Filipi, medical director of quality advancement for Blue Cross Blue Shield of Nebraska. Medical home doctors and staff have more responsibility for reaching out to a patient who isn't coming in or isn't managing a chronic disease, such as diabetes.
“In the old days, that person would just be off the radar screen,” Filipi said. But by keeping that patient out of the emergency room, everyone saves money. “I believe that it does have financial value in the long run,” he said.
While Blue Cross is expanding its project, Dr. Bob Rauner of Lincoln said Nebraska's two other major insurers — United HealthCare and Coventry — have been slow to support medical home clinics. Rauner is chairman of the Nebraska Medical Association's medical home committee.
Rauner said the insurance firms evidently prefer a short-term return on investment to a long-term return. Insured groups frequently sign on with another insurer after only a couple of years, and the savings would go to another firm.
The medical home concept generally requires an ongoing relationship between the patient and a primary care doctor; a care coordinator who stays on top of patients by phone or email; and the use of computer technology and software to categorize and track patients with specific conditions.
In the typical primary care practice, a doctor gets paid for doing things — seeing a patient, getting lab work done, removing a toenail, doing an EKG. The more patients the doctor sees and the more things she does, the more she's compensated.
But in the medical home, the physician's care coordinator stays in touch with the patient and reminds him to stay vigilant in managing his diabetes, monitoring his blood sugar levels, eating right and staying healthy.
Cannizzaro Wilson, a 49-year-old Omahan, offered testimony to the value of the concept. Wilson has lived with severe diabetes for 18 years. He has landed in emergency rooms and hospital beds multiple times with his disease.
“I guess you could say I cheated death a couple of times because of how high my sugar has been,” he said.
Wilson works at a fast-food restaurant and doesn't have health insurance, but he hooked up with the UNMC Physicians Midtown medical home on 40th Street. Clinic case manager Susan Burbach told him two years ago that if he stayed true to his treatment plan, the clinic would help him out as much as it could.
“She set a goal for me to stay out of the hospital, so I'm coming up on two years for that,” he said of the last time he was hospitalized.
Burbach and Wilson stay in touch with each other by phone. He injects himself with insulin, monitors his blood sugar level and visits the clinic regularly. The clinic has given him financial help that comes from UNMC Physicians and a pharmaceutical company.
“I'm in much better shape now than I was since the first year when I was diagnosed with diabetes,” he said. “Because if I don't keep up on it, it'll get me.”
Dr. Tom Tape, an internal medicine physician at the clinic, said the medical home has 2,500 patients who are seen largely by about 45 resident doctors (recent medical school graduates). Nine attending physicians supervise the care provided by the residents.
The clinic includes a social worker, a psychologist, a smoke-cessation clinic, on-site cooking classes, diabetes education classes, a pharmacy intern and the capacity to do some lab work.
Tape said the medical home, which isn't linked to the Blue Cross Blue Shield project, is supported financially by UNMC Physicians, the Nebraska Medical Center and the UNMC medical school.
For the long haul, though, clinics like this will need backing from insurers, Tape said, or from Medicaid and Medicare.
Dr. Paul James, chairman of the department of family medicine at the University of Iowa, said medical homes over the long run improve care and reduce costs. “When you think of the health care situation in America, that is what we're looking for,” James said.
Iowa Medicaid has participated in some medical home test projects and will be involved in more this year. Otherwise, insurance participation in Iowa medical homes has been minimal.
Blue Cross in Nebraska has expanded its support for medical home clinics. The company, which maintains close to 50 percent of Nebraska's private health insurance market, now includes 164 Nebraska doctors and 33 clinics in its medical home program.
The initiative now covers patients with diabetes, vascular disease, childhood asthma and other chronic conditions. Whether an office functions as a medical home can be determined by a state, a participating insurance firm or an organization such as the National Committee for Quality Assurance.
Blue Cross pays for computer software to help doctors organize data and gives a monthly fee of $2.50 per patient and a performance bonus at the end of the year. For a five-doctor clinic seeing 80 diabetic patients, the clinic could receive close to $10,000 a year. It would receive additional money for seeing patients with other chronic illnesses. Because each patient's and each clinic's situation is different, whether that funding would cover all the upfront costs remains to be seen.
Nebraska Medicaid has overseen two test clinics for the medical home concept, one in Kearney and the other in Lexington, and has required United HealthCare, Coventry and Arbor Healthcare to participate in several medical home projects through those entities' state Medicaid contracts.
A Coventry spokeswoman said through an email that her firm “is interested in Medical Home partnerships” and “continues to seek avenues to cooperate with physicians and hospitals to provide quality, affordable care.”
United HealthCare said it's working on a medical home project with People's Health Center in Lincoln. A United spokeswoman said through email that in this project and others across the country, the firm “is tracking and studying several cost and quality metrics to help determine the necessary and essential elements for ongoing health and primary care reform.”
The Nebraska Legislature's Banking, Commerce and Insurance Committee this year will study ways that health policies and contracts might benefit medical homes. In Maryland, state law requires several major health insurers to participate in a medical home initiative.
State Sen. Mike Gloor of Grand Island, a supporter of the medical home concept and member of the committee, said he wants more information on the matter. He said Blue Cross, United and Coventry will be included in the discussion.
He said he doesn't necessarily expect the study to lead to legislation requiring major insurance firms to support the medical home concept. But Gloor added: “It's always a possibility.”
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