The Primary Care Renewal project really began in 2002 and 2003—years when CareOregon’s future looked bleak. A recession had recently hit, and then the Oregon Health Plan announced severe cuts to its rolls. “We were facing a problem of nearly going out of business,” says CareOregon’s Labby. “We knew we couldn’t just expect more money [from the government] just because medical costs were rising. We had to have a long-term, sustainable business model.”

Patients with difficult, chronic medical problems were by far the most expensive to treat. Twelve percent of CareOregon’s clients used some 60 percent of the funding. “Data shows that when you have two, three, four medical conditions, costs skyrocket,” Labby says. CareOregon wondered whether it could reduce the money spent on these patients by helping community health centers, which serve many of CareOregon’s clients, focus on those with chronic conditions. “The more you can help these people stay healthy, the more you have a chance of keeping them out of the costly emergency room and out of the hospital. That’s good for them and good for you,” Labby says.

Labby, a general internist, anthropology PhD, and close follower of health care theory, had been reading about Southcentral Foundation Anchorage Native Primary Care Center, a clinic that was doing things differently. Located in Anchorage, Alaska, the clinic once faced precisely the kinds of problems that many health centers do: patients had to wait weeks—even months—for an appointment, which increased demand for costly urgent appointments and prevented patients from getting the health care they needed.

Then a new administrator came in and insisted the clinic could, and would, deliver world-class health care to the region’s Native Americans. Over a period of years, the staff jettisoned the old way of working and, together with patients, rewrote a primary model focused on giving every patient the kind of care he needed—and wanted—when and how he wanted it. “They call their patients ‘customer owners,’” Labby says of the patient-centered approach. “Because if you think about where the money comes from, it comes from employers and taxpayers.” Not only did the clinic work to improve its customers’ physical health, but it also worked on their mental and behavioral health problems—a practice known as whole-person care in popular medical parlance.

In 2006, Labby and thirty others—CareOregon staff, local community health center managers, and even state legislators—took a trip to Alaska. It’s not an exaggeration to say the trip had a profound effect. “I took three pages of notes in the first hour,” says Craig Hostetler, executive director of the Oregon Primary Care Association. “Everything they did was centered on a strong relationship with the patient and the family—not just cranking a patient through.”

And the resulting data was staggering: by employing phone consultations and allowing patients to see nurses in lieu of doctors for certain procedures, the clinic drove down wait times so that every patient who needed an appointment could be seen the very day he or she called. As the number of regular visits with family physicians rose, the number of costly urgent care visits dropped. (The clinic logged some 3,300 urgent care visits in July 2002, before the changes took full effect, and just some 2,000 in July 2007, an all-time low.) The number of emergency room visits also fell, from fifty-nine per one thousand patients in January 2000 to thirty-five per thousand in January 2008. Southcentral, which serves fifty-five thousand Native Americans at every income level, now is recognized as a model for how health care systems should function.

But Southcentral had some advantages that Portland’s community care centers do not—it receives a set amount of money per patient from Indian Health Services and other agencies (along with some other fee-for-service funding), which means that clinic leaders can spend the money as they see fit. Also, Southcentral is affiliated with a hospital and a mental health center. This makes whole-person care a bit easier to manage. Was it possible, CareOregon and Portland clinic directors wondered, to replicate the excellent care within the limits of a fee-for-service system? “Ultimately, we agreed that we couldn’t not try it,” Labby says.

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