Pilot Plan on Health an Option for States

Pilot Plan on Health an Option for States

Shirley Wang, Wall Street Journal, June 10, 2010

WILLOW GROVE, Pa.—An early look at Pennsylvania's experiment in delivering better and, in the long run, less-expensive health care underscores the challenges and potential benefits of one idea being explored as part of the health overhaul.

Known as a "patient centered medical home," the approach aims to better coordinate care to avoid gaps or overlapping efforts. The main tenet is that a primary-care provider oversees care with a team of health professionals and coordinates with resources in the community, according to the NationalCenter for Quality Assurance, an independent, nonprofit organization that recognizes practices as "medical homes."

The approach is designed to provide care in a more structured and organized way than traditional medical practices, but it can involve more personnel and higher costs, at least initially.

The health-overhaul law is likely to provide funding for pilot projects to investigate the costs and benefits of medical homes. More than a dozen states have already begun conducting their own projects to test whether the approach is feasible and produces the expected results.

In the long run, more coordinated care should lower health-care costs by reducing inefficiencies such as redundant tests, and because patients with better control over chronic conditions won't need expensive emergency care as frequently. So far, results have been mixed.

Pennsylvania is carrying out the largest state pilot program in the U.S.—called the Chronic Care Initiative—which involves more than one-million patients, 800 doctors and 16 insurers across seven regions of the state. Insurers are providing $30 million over three years in extra payment to doctors who are involved, and the state is contributing $3.4 million to run the program.

"There is a lot of chaos in primary care," said Ann Torregrossa, director of the Governor's Office of Health Care Reform in Pennsylvania. Her office works with practices to better manage work flow, use staff "very intelligently" and "not put everything on the shoulders of doctors," said Ms. Torregrossa.

In 22 doctors' practices across southwestern Pennsylvania involving 7,500 diabetic patients, the percent of patients with high blood-sugar levels—a sign that their diabetes isn't in good control—fell to 24% from 29% after nine months in the program, according to data from the governor's office presented at a recent meeting in Wexford, Pa. A similar trend was seen in practices in south-central and southeastern Pennsylvania.

Diabetes can be difficult and expensive to treat, so these data were a promising sign that care for chronic disease can improve.

Some 67% of the patients exhibited blood pressure in the normal range, up from 55%. In south-central Pennsylvania, the figures were even more striking, with 70% of diabetics reaching a normal blood pressure, up from 46% nine months earlier.

To be sure, there are challenges to implementing the approach. On Monday, results from a national pilot project involving 36 family practices demonstrated that medical homes can be successfully implemented, but the "transformation requires tremendous effort and motivation," according to a paper published in the journal Annals of Family Medicine.

Changes often involve adding an electronic medical-records system and substantially training or reorganizing staff.

And the data showed limited clinical benefits for patients in the project, which was funded by the American Academy of Family Physicians and the Commonwealth Fund, a private foundation that aims to improve health care. Patients showed improvement on clinical measures that assessed chronic disease and prevention, but patients' ratings of practices fell.

In Pennsylvania, diabetic Aretha Swift, 50 years old, said the medical home approach improved her health. Her doctor's participation has meant getting calls at work checking in to see how she is doing, cheerleading when she takes her pills and problem-solving with her when she doesn't.

There are monthly group meetings for patients so she can commiserate and exchange ideas with other diabetics who see the same doctors. And, when she was admitted to the hospital recently for dangerously high blood pressure, two medical assistants from her primary-care doctor's office came to visit her.

"They're genuinely concerned about my welfare," said Ms. Swift, a housing specialist from Glenside, Pa., near Philadelphia.

Her doctor, Cynthia Salinas, and the other four physicians in the North Willow Grove Family Medicine practice have seen their group of nearly 600 diabetics exhibit improved control over their blood sugar. And the patients have had more regular foot and eye exams, which are important because diabetes can lead to amputations and blindness.

The practice had to add the equivalent of 2.5 full-time staff members and trained medical assistants to take on more duties. Patients are pushed to take more control over their disease, coming up with health goals at each doctor's visit, and so-called health coaches call to follow up with patients.

The team approach has benefited patients as well as the doctors. "It's made my work as a physician a lot less stressful," said Dr. Salinas.

All these changes cost money. The practice where Ms. Swift is treated had to add the equivalent of 2.5 full-time staff members and trained medical assistants to take on more duties. For doctors involved in the initiative, the key question is how sustainable it is.

Bryan Negrini, an internal medicine doctor at the University of Pittsburgh Medical Center, said that the program had been beneficial for his patients because the practice had become "proactive, not reactive." The implementation has been time-consuming and expensive, however.

"The big question is what will happen after year one?" said Dr. Negrini. "Is this all fluff for political reasons or a sustainable model for the benefit of our patients?"

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