Over 500 Docs And Nurses Providing Care In Medical Homes

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More than 500 primary care doctors and nurses are now working in patient-centered medical homes, an increasingly popular health care strategy that advocates say improves care and cuts costs.

As of mid-April, 121 medical offices in Connecticut have gained certification to operate as medical homes from the National Council of Quality Assurance, the leading certifying organization. That number includes 67 locations under ProHealth Physicians, the largest group participating.

The quality assurance council, an independent, non-profit organization, also has certified 511 clinicians who meet the criteria set for medical home standards. That number includes both primary care physicians and nurses, although the total number may well be even higher, as other certifying groups, including insurers, separately are recognizing practices and physicians, health experts say.

Connecticut’s totals pale in comparison to the number of medical homes nationally, but as a percentage of practices, the state ranks ninth nationally, with 17 percent of primary care physicians following medical home standards, officials say.

It’s too early to say whether medical homes in Connecticut will ultimately meet the goal of improving care and reducing costs, some experts say.  But pilot programs in other states, such as New York, have resulted in patient hospital admission rates dropping as much as 23 percent and emergency rate admissions declining as much as 17 percent, according to Bernadette Kelleher, vice president of provider engagement and contracting for Anthem Blue Cross Blue Shield, which ran the New York pilot. Similar studies in Colorado, Oregon and Pennsylvania showed costs stabilized the first year and dropped the second year.

At its core, the medical home’s goal is to improve health care quality and efficiency by relying heavily on electronic medical records and electronic prescribing, improving access and communication, tracking patients and referrals, and reporting performance.
To do that, primary care physicians become the quarterbacks or team coordinators of their patients’ care, and patients’ medical records are housed electronically at their primary doctors’ offices.

Dr. David Howlet, a 59-year-old family physician runs a medical home in north-central Connecticut at East Granby Family Practice. Near front-desk assistants who check in patients, two triage nurses make phone calls and work their computers, ensuring that no patient falls through the medical system’s cracks.

Those triage nurses set appointments for elderly patients and others who need help seeing specialists; and they create electronic-message reminders which pop up at future dates, so the nurses can track referrals and order tests.  As a result the triage nurses are on top of whether patients actually get scheduled colonoscopies or mammograms, for example.

Blocks of each day’s office schedule also are reserved for urgent visits.  Office hours are extended on Mondays and Thursdays and the office is open on Saturdays too.

“It keeps people out of the emergency room,’’ says Howlett, referring to the greater access and accountability procedures, both criteria for medical homes.

Two years ago medical homes were scarce in Connecticut, as physicians nationally rapidly embraced the trend.

One reason Connecticut doctors were slow to embrace medical homes is the cost for computer equipment and software can run in the tens of thousands of dollars, doctors and policy experts say.

Despite the lack of financial incentives, more physicians are moving toward the model because of the increasing number of pilot and training programs offered.  Earlier this year Anthem Blue Cross Blue Shield and Aetna and the Connecticut State Medical Society launched pilot medical home programs.

Also, Gov. Dannell Malloy’s administration has made medical homes a key component of the state’s plan to control costs for Medicaid programs, and health insurance programs that cover state employees and retirees.

In March, Comptroller Kevin Lembo announced that health insurance premiums for state employees for the next fiscal year won’t increase, partly because of an initiative encouraging employees and retirees to see physicians in medical homes.

This year, state officials replaced private insurance companies with a single administrative services organization to manage care for adults and children covered by Medicaid, HUSKY and Charter Oak.  The organization will coordinate services and roll out its medical homes program.

“There’s been considerable momentum,” says the state’s Medicaid director Mark Schaefer, referring to the growing popularity of medical homes. “Medicaid throwing its weight into this has helped considerably.”

Reliance on technology also saves money and maintains patients’ health in other ways, advocates say.

Community Health Center, Inc., a statewide non-profit organization with 11 medical sites, converted to the medical home model last year. Because of electronically generated performance reports, physicians discovered that only 10 percent of their diabetic patients were following up with critical screenings that test for eye disease. Left untreated, it causes blindness.

But now the center participates in a telemedicine program with Yale’s ophthalmology department, taking images of diabetic patients’ eyes in the center’s health clinics, uploading the images, and getting results from Yale within 24 hours, says J. Nwando Olayiwola, the center’s chief medical officer, who led Community Health’s efforts to become a medical home.

One focus of Anthem Blue Cross Blue Shield’s pilot program launched with 30 Connecticut physicians in February offers similar performance information that medical home advocates say helps reduce costs.

“If you ask me how many patients are utilizing the emergency room and walk-in clinic in your local area, and even more so how many are unnecessarily utilizing them, I couldn’t tell you. I have no idea,” says Dr. Stacy Taylor, president of the Connecticut Academy of Family Practices and a physician in Torrington, who is involved in the Anthem pilot.

With aggregate numbers, which Anthem will collect during the pilot, Taylor and other participating physicians will have that data. Armed with that, she says, they can begin to train patients to call their doctors first and take advantage of increased office hours, measures that could cut reduce the number of ER visits and high costs associated with those admissions.

One challenge for the state is that more than 60 percent of practices are small or solo practices; many physicians also are older than their peers across the nation.

“If I’m on the verge or retiring, I wouldn’t spend the money for an electronic medical record,” says Dr. Michael M. Krinsky, a neurologist practicing in Bloomfield and president of the state Medical Society.

Costs vary, but it can take anywhere from $20,000 to $100,000 to incorporate a full electronic system into a practice, Krinsky says.  Howlett’s East Granby practice has spent $400,000 over the past seven years to keep its software and systems updated, including fees for licenses, and hardware updates. He says it took him 162 hours to put together the procedures and protocols and other requirements for certification. “It was like doing a project for college, like a thesis paper,” he recalls.

Insurers are beginning to roll out programs that reward physicians for cost savings, but physicians say they don’t begin to cover the cost to finance medical homes. Under Aetna’s new pilot, for example, participants will earn quarterly payments for each Aetna member they treat. Some 150 qualified physicians in the state are participating. They’ll get up to $9 per member per month each quarter.

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