Health care reform is by no means something that's just being imposed from the top down by governmental mandates. It's also emanating from the bottom up with initiatives on the part of doctors to change the way they practice medicine and get compensated.
A Knoxville-based physician group is in the forefront of implementing a new model of patient care that's getting lots of national acclaim. So it's instructive to talk to the change agents who lead this group about what they've been doing to implement this model and why they believe it will lead to both improved quality of care and systemic cost containment.
With 220 member physicians, the Summit Medical Group is the Knoxville area's largest provider of primary care. And it's one of only two groups in the state to have gotten national recognition for embracing the model known as the patient-centered medical home.
While the origins of this model date back to the 1960s in pediatric care, its principles have only recently gained recognition from other physician organizations, including the American Academy of Family Physicians and the American Medical Association. In a medical home, each patient has a doctor with primary responsibility for overseeing all facets of a person's treatment, encompassing preventive care, outpatient testing and procedures, referrals to specialists, hospitalization and its aftermath. Critically, the doctors are supported by nurses known as care management coordinators who follow up with patients who are systematically identified as needing attention for things like adherence to medication regimens or recurrence of symptoms that warrant further attention.
This "whole person orientation," as Summit's Chief Medical Officer Dr. Randall Curnow refers to it, is "ending the tyranny of the 15-minute office visit in which the fee-for-service model [for paying doctors] has sort of trapped us." And he warns that "unless physicians are incentivized and have the resources and tools in place for more vigorously coordinated care, there will be no other recourse but to continue going down the utilization fee-for-service path we're on, and that will lead us to ruin."
As it happens, those who pay most of the bills (insurance companies and managers of self-insured employer health plans) are buying into the medical home model and offering incentive payments for its adoption, tied to certifications by the National Committee for Quality Assurance. Hospitals are beginning to follow suit with incentives aimed primarily at preventing readmission of patients who've been discharged. That's due in large part to the fact that Medicare is moving to deny hospitals reimbursement for anyone who is readmitted within 30 days of discharge.
For now, incentive payments are largely based on adherence to processes starting with NCQA standards. But Curnow foresees a movement toward payment for performance based on patient outcomes. "This is in its infancy and there is debate within the industry on what we actually should incentivize," he says. "Part of the debate is that patients have to have an active role, and if a patient doesn't want to pursue treatments that will best improve their outcomes, what do you do? But part of the medical home model is to engage patients in their care, to help them take more responsibility, and for patients with certain diseases to become more compliant with taking medications that really impact those diseases."
While the medical home model empowers primary care doctors to coordinate patient care, Summit CEO Tim Young insists it doesn't represent a reversion to the managed care or HMO mode of the 1990s in which primary care doctors served as gatekeepers controlling patient access to specialists and other services.
"The incentive there was to do less whereas the incentive in this model is to do what's clinically appropriate," he says. "And it's tempered with something that the old HMO model didn't have which were safeguards around quality and outcomes with incentives for physicians to invest in infrastructure to augment themselves... And the standards are set by an objective third party, NCQA, which is like a Good Housekeeping Seal of Approval, that demonstrate to health plans and consumers that Summit has got systems in place to achieve these outcomes."
While convinced the uncoordinated fee-for-service model is "unsustainable in terms of affordability," Young won't go so far as to predict that medical homes will result in lower health care costs. "We've got an aging population, and everybody knows that health care is going to cost more in the future," he asserts. "But I think most experts have come to realize we've got to fundamentally change how care is delivered and that you've got to reward people and providers in that system differently so as to incentivize them to improve outcomes, create value ... and ultimately those things are not incongruent with lowering cost."
The health care legislation that Congress enacted earlier this year is replete with references to medical homes, including provisions for pilot programs under both Medicare and Medicaid.
Geisinger Health Plan in Pennsylvania is widely recognized as a leader and the largest in the field. Summit Medical believes it is the third largest in the nation after Geisinger and Health Partners Medical Group in Minnesota.
It's heartening to realize that the Knoxville area is in the forefront of forging what could well become the wave of the future in raising the quality of health care in this country on a more cost effective basis.