Maryna Thompson, Legacy Emanuel’s internal medicine clinic manager, calls herself a “crusty old nurse,” but that’s a cover. She’s a small, high-energy woman of fifty-five with dark hair that’s crisply bobbed. A former CareOregon board member, she came to the teaching clinic two years ago to implement the medical home here.
“Sometimes I liken the [old way of doing things] to [throwing] a party, but you didn’t know how many guests would show up or what they wanted,” she says. She shows me the screening tool her staff created to improve their chronic care management—essentially a checklist of preventive tests, immunizations, and labs. Stored in the patient’s file and updated at every visit, the sheet is an example of how simple changes can have a big effect. Since the clinic began the Primary Care Renewal project, the number of diabetics who miss their scheduled blood sugar tests has dropped by 26 percent.
Most impressive is how the clinic has saved CareOregon money. By pulling claims data, Thompson found that out of the clinic’s nearly four thousand patients, about fifty were chronically going to the emergency room; after interviewing them, Thompson found they were overusing the ER for a variety of reasons. “Maybe it was for chronic pain or psychosocial issues, or maybe just because they didn’t want to wait to be seen here,” she says. The nurses, behavioral health consultant, and pharmacists decided, as a group, to give those patients even more attention—in some cases, Thompson called members of the patient’s family and invited them to participate in discussions about the patient’s health plan. “We had to get them back and get them engaged with us,” she explains.
The results are paying off. By getting just fifteen to twenty of those patients to use the emergency room less frequently, the clinic is saving CareOregon about $1 million per year. Thompson’s group did the same for no-shows. They pulled a list of patients who chronically missed appointments and called each one—not once, but twice. The no-show rate has dropped by 20 percent.
Those figures seem to prove that the medical home model can improve care. Then again, these clinics are highly motivated. Not all doctors want to change the way they care for patients, or reorganize their offices. Plus, there is the more pressing matter: if it weren’t for the CareOregon grant, there would be no incentive, other than magnanimity, for these clinics to make such radical adjustments. The truth is, even if these five clinics prove the model can work, insurance companies must support primary care in a way that actually promotes better health care. “We’re still operating in a widget-based system,” Labby tells me. “[CareOregon] started with the simple idea that [a doctor’s] job is the health of the population. Your job is not your schedule. If your job is your schedule, then your job is not health but [rather] only the number of people who are coming through the door.”
This year, CareOregon will begin paying each clinic not just for visits but also for outcomes. But if the medical home is going to become the standard for primary care, then most, if not all, health insurance companies will have to restructure their businesses. “We might be able to demonstrate the outcomes, but the question is, Can the payment system change to support us?” says Thompson. “We’re locked into a pay-per-visit system, and changing that is the key to transformation.”
The difficulties of cultural change apply just as strongly to the health insurance industry, though. “There is skepticism about whether [the medical home] saves money, about whether the delivery system is capable of change,” says Ralph Prows, senior medical director of Regence BlueCross BlueShield of Oregon, which has been funding what Prows calls a “medical-home light” pilot project of its own. Yet increasingly, insurers are realizing that the fee-for-service system isn’t working for their bottom lines, either. “Double-digit increases in medical costs are not sustainable,” Prows says. “And we’re meeting recommendations [for patient care] about half the time. It’s like a coin toss.”
Perhaps, as Labby hopes, clinics that prove costs are lower, patients are more satisfied with their care, and health outcomes are better under the medical home model will gain a competitive advantage and cause a kind of systemwide shift in approach. Or perhaps the change will happen in a more dramatic fashion.
Hostetler, of the Oregon Primary Care Association, once sat on a panel about the future of Oregon health care. When asked what he hoped for, his response shocked the audience. “I said I hope the system gets so bad that we have to throw it out,” he recalls.
If it does, perhaps community health centers—those safety nets for the toughest cases—will be recognized and copied for embracing a model of care that actually makes people healthier.
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