Patient-Centered Medical Home Experiment Shows Promise

WASHINGTON — Results from trials of a patient-centered medical home suggest that such arrangements result in cost savings and reduced hospital readmissions, according to Dr. Barbara Walters, senior medical director of southern New Hampshire community group practices at the Dartmouth-Hitchcock health care system.

Dr. Walters' organization is involved in a medical home trial sponsored by the Centers for Medicare and Medicaid Services that includes 10 multispecialty groups operating in a fee-for-service environment. Under the trial protocol, the practices are responsible for the entire cost of care for their Medicare patient population; they receive per-patient monthly fees for care management.

Dartmouth-Hitchcock got a $6.8-million bonus in 2008 because of the money the groups saved Medicare, and the 3-year project has been extended an additional 2 years. “On 35,000 Medicare patients, we saved $10 million for the Medicare trust fund,” she said at the sixth annual World Health Care Congress.

Key to the clinical intervention was the transformation of the registered nurses' role. “Our nurses used to be 'triagers' and traffic cops. We didn't take their licensure and their scope of their ability to practice into account,” said Dr. Walters. “Now they are health coaches, patient advocates, and referral coordinators.”

Training staff in proper coding also helped. “We needed to train all of our doctors,” she said, because, like it or not, severity adjustment and the total cost of care is assessed by the diagnoses that go on the claims form.

Dartmouth-Hitchcock also developed a registry that “allows you to look at [an] individual patient and get a snapshot of all the key indicators that help their health,” said Dr. Walters, adding that “you can look at the entire population of patients … so that you can take care of the health of the population of [for example] the diabetics or congestive heart failure [patients] that you serve.”

Protocols were developed for postdischarge phone calls. “The nurse calls the day after you get out of the hospital, checks to make sure patients understand which medications they're supposed to take, which medications they're no longer supposed to take, and gets them into their primary care doctor, their medical home,” Dr. Walters said.

As a result of these changes, every single practice in the pilot had lower risk-adjusted costs of care and admission rates and better quality measures than a comparison group, she said.

In addition, while hospital readmission rates are typically upwards of 20%, “we talked to the Cleveland Clinic; they got theirs down to 14%. In one of our communities where we're the only provider, we got it down to 9%,” Dr. Walters said.

The results have spurred a partnership between Dartmouth-Hitchcock and CIGNA to develop a pilot medical home project.

Under that project, the practice hopes to improve on the Medicare model and get primary care physicians to reap more financial benefit from any money saved. Dartmouth-Hitchcock wants to include ongoing payments for care management, “which is the biggest [implementation] issue across every group that we talked to,” said Dr. Walters. “There's lots and lots of nonvisit care that you can apply” if the payment system allows for it.

That's easier to do in a system like Kaiser Permanente, where one entity owns the whole delivery system, she continued, “but those of us who practice in a fee-for-service world, where we only get reimbursed for individual-based care when patients come in, we need some slack in the system for us to be able to build the infrastructure so we can do e-visits, nurses can develop care plans, and nurses can call patients before a visit and have the lab work done when they show up” to visit the doctor. The CIGNA program only began in April, so no results are available yet, she said.

Health care organizations increasingly are looking at patient-centered medical homes, according to Edwina Rogers, executive director of the Patient-Centered Primary Care Collaborative in Washington, D.C., whose 475 members include large employers, primary care physician associations, health insurers, trade associations, academic centers, and health care quality improvement associations.

Ms. Rogers cited research from Johns Hopkins University, Baltimore, showing that adults who have a primary care physician coordinating their care had 33% lower costs of care and were 19% less likely to die.

The 3-year-old collaborative is currently involved with 22 pilot medical home projects in 16 states. The model used by the collaborative includes a monthly care coordination fee in addition to fee-for-service payments and performance bonuses.

Figuring out which outcomes to analyze and report on “is the hardest part to do,” said Ms. Rogers. A group led by the U.S. Department of Health and Human Services is “trying to figure out standard outcome measures that we can all agree on. … That's probably one of our biggest problems.”

'On 35,000 Medicare patients, we saved $10 million for the Medicare trust fund' over 3 years. DR. WALTERS

WASHINGTON — Results from trials of a patient-centered medical home suggest that such arrangements result in cost savings and reduced hospital readmissions, according to Dr. Barbara Walters, senior medical director of southern New Hampshire community group practices at the Dartmouth-Hitchcock health care system.

Dr. Walters' organization is involved in a medical home trial sponsored by the Centers for Medicare and Medicaid Services that includes 10 multispecialty groups operating in a fee-for-service environment. Under the trial protocol, the practices are responsible for the entire cost of care for their Medicare patient population; they receive per-patient monthly fees for care management.

Dartmouth-Hitchcock got a $6.8-million bonus in 2008 because of the money the groups saved Medicare, and the 3-year project has been extended an additional 2 years. “On 35,000 Medicare patients, we saved $10 million for the Medicare trust fund,” she said at the sixth annual World Health Care Congress.

Key to the clinical intervention was the transformation of the registered nurses' role. “Our nurses used to be 'triagers' and traffic cops. We didn't take their licensure and their scope of their ability to practice into account,” said Dr. Walters. “Now they are health coaches, patient advocates, and referral coordinators.”

Training staff in proper coding also helped. “We needed to train all of our doctors,” she said, because, like it or not, severity adjustment and the total cost of care is assessed by the diagnoses that go on the claims form.

Dartmouth-Hitchcock also developed a registry that “allows you to look at [an] individual patient and get a snapshot of all the key indicators that help their health,” said Dr. Walters, adding that “you can look at the entire population of patients … so that you can take care of the health of the population of [for example] the diabetics or congestive heart failure [patients] that you serve.”

Protocols were developed for postdischarge phone calls. “The nurse calls the day after you get out of the hospital, checks to make sure patients understand which medications they're supposed to take, which medications they're no longer supposed to take, and gets them into their primary care doctor, their medical home,” Dr. Walters said.

As a result of these changes, every single practice in the pilot had lower risk-adjusted costs of care and admission rates and better quality measures than a comparison group, she said.

In addition, while hospital readmission rates are typically upwards of 20%, “we talked to the Cleveland Clinic; they got theirs down to 14%. In one of our communities where we're the only provider, we got it down to 9%,” Dr. Walters said.

The results have spurred a partnership between Dartmouth-Hitchcock and CIGNA to develop a pilot medical home project.

Under that project, the practice hopes to improve on the Medicare model and get primary care physicians to reap more financial benefit from any money saved. Dartmouth-Hitchcock wants to include ongoing payments for care management, “which is the biggest [implementation] issue across every group that we talked to,” said Dr. Walters. “There's lots and lots of nonvisit care that you can apply” if the payment system allows for it.

That's easier to do in a system like Kaiser Permanente, where one entity owns the whole delivery system, she continued, “but those of us who practice in a fee-for-service world, where we only get reimbursed for individual-based care when patients come in, we need some slack in the system for us to be able to build the infrastructure so we can do e-visits, nurses can develop care plans, and nurses can call patients before a visit and have the lab work done when they show up” to visit the doctor. The CIGNA program only began in April, so no results are available yet, she said.

Health care organizations increasingly are looking at patient-centered medical homes, according to Edwina Rogers, executive director of the Patient-Centered Primary Care Collaborative in Washington, D.C., whose 475 members include large employers, primary care physician associations, health insurers, trade associations, academic centers, and health care quality improvement associations.

Ms. Rogers cited research from Johns Hopkins University, Baltimore, showing that adults who have a primary care physician coordinating their care had 33% lower costs of care and were 19% less likely to die.

The 3-year-old collaborative is currently involved with 22 pilot medical home projects in 16 states. The model used by the collaborative includes a monthly care coordination fee in addition to fee-for-service payments and performance bonuses.

Figuring out which outcomes to analyze and report on “is the hardest part to do,” said Ms. Rogers. A group led by the U.S. Department of Health and Human Services is “trying to figure out standard outcome measures that we can all agree on. … That's probably one of our biggest problems.”

'On 35,000 Medicare patients, we saved $10 million for the Medicare trust fund' over 3 years. DR. WALTERS

WASHINGTON — Results from trials of a patient-centered medical home suggest that such arrangements result in cost savings and reduced hospital readmissions, according to Dr. Barbara Walters, senior medical director of southern New Hampshire community group practices at the Dartmouth-Hitchcock health care system.

Dr. Walters' organization is involved in a medical home trial sponsored by the Centers for Medicare and Medicaid Services that includes 10 multispecialty groups operating in a fee-for-service environment. Under the trial protocol, the practices are responsible for the entire cost of care for their Medicare patient population; they receive per-patient monthly fees for care management.

Dartmouth-Hitchcock got a $6.8-million bonus in 2008 because of the money the groups saved Medicare, and the 3-year project has been extended an additional 2 years. “On 35,000 Medicare patients, we saved $10 million for the Medicare trust fund,” she said at the sixth annual World Health Care Congress.

Key to the clinical intervention was the transformation of the registered nurses' role. “Our nurses used to be 'triagers' and traffic cops. We didn't take their licensure and their scope of their ability to practice into account,” said Dr. Walters. “Now they are health coaches, patient advocates, and referral coordinators.”

Training staff in proper coding also helped. “We needed to train all of our doctors,” she said, because, like it or not, severity adjustment and the total cost of care is assessed by the diagnoses that go on the claims form.

Dartmouth-Hitchcock also developed a registry that “allows you to look at [an] individual patient and get a snapshot of all the key indicators that help their health,” said Dr. Walters, adding that “you can look at the entire population of patients … so that you can take care of the health of the population of [for example] the diabetics or congestive heart failure [patients] that you serve.”

Protocols were developed for postdischarge phone calls. “The nurse calls the day after you get out of the hospital, checks to make sure patients understand which medications they're supposed to take, which medications they're no longer supposed to take, and gets them into their primary care doctor, their medical home,” Dr. Walters said.

As a result of these changes, every single practice in the pilot had lower risk-adjusted costs of care and admission rates and better quality measures than a comparison group, she said.

In addition, while hospital readmission rates are typically upwards of 20%, “we talked to the Cleveland Clinic; they got theirs down to 14%. In one of our communities where we're the only provider, we got it down to 9%,” Dr. Walters said.

The results have spurred a partnership between Dartmouth-Hitchcock and CIGNA to develop a pilot medical home project.

Under that project, the practice hopes to improve on the Medicare model and get primary care physicians to reap more financial benefit from any money saved. Dartmouth-Hitchcock wants to include ongoing payments for care management, “which is the biggest [implementation] issue across every group that we talked to,” said Dr. Walters. “There's lots and lots of nonvisit care that you can apply” if the payment system allows for it.

That's easier to do in a system like Kaiser Permanente, where one entity owns the whole delivery system, she continued, “but those of us who practice in a fee-for-service world, where we only get reimbursed for individual-based care when patients come in, we need some slack in the system for us to be able to build the infrastructure so we can do e-visits, nurses can develop care plans, and nurses can call patients before a visit and have the lab work done when they show up” to visit the doctor. The CIGNA program only began in April, so no results are available yet, she said.

Health care organizations increasingly are looking at patient-centered medical homes, according to Edwina Rogers, executive director of the Patient-Centered Primary Care Collaborative in Washington, D.C., whose 475 members include large employers, primary care physician associations, health insurers, trade associations, academic centers, and health care quality improvement associations.

Ms. Rogers cited research from Johns Hopkins University, Baltimore, showing that adults who have a primary care physician coordinating their care had 33% lower costs of care and were 19% less likely to die.

The 3-year-old collaborative is currently involved with 22 pilot medical home projects in 16 states. The model used by the collaborative includes a monthly care coordination fee in addition to fee-for-service payments and performance bonuses.

Figuring out which outcomes to analyze and report on “is the hardest part to do,” said Ms. Rogers. A group led by the U.S. Department of Health and Human Services is “trying to figure out standard outcome measures that we can all agree on. … That's probably one of our biggest problems.”

'On 35,000 Medicare patients, we saved $10 million for the Medicare trust fund' over 3 years. DR. WALTERS