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PUBLIC HEALTH POLICY IN AMERICA

Our presidential election is only days away. Forty eight million people in America are uninsured and health care costs are rising 2-3 times faster than our nation’s GDP. Where will America’s healthcare system be in 5 years? Welcome to ReachMD’s monthly series focus on public health policy. This month, we explore the many questions facing healthcare today.

The medical home, a term doctors and patients will increasingly hear about as a way to improve patient care and perhaps rate in healthcare cost is gaining momentum, whether it be in your local healthcare delivery system or out on the campaign trail with senators Obama and McCain.

Welcome to ReachMD XM 157, the channel for medical professionals. I am Bruce Japsen, the healthcare reporter with the Chicago Tribune and with me today is Toni Mills. She is the Executive Director of the Office of Clinical Affairs for the BlueCross and BlueShield Association. As executive director, she is responsible for the programatic leadership or activities that include initiatives to improve patient safety for the association’s 39 independent locally operated BlueCross and BlueShield, health insurance companies across the country. In her role, she works to develop new relationships with quality and physician organizations to ensure operational excellence. Before coming to the BlueCross and BlueShield Association, she held various positions at CNA Insurance and United States Life Insurance Company responsible for everything, from operations for financial reporting, claims, utilization review. Toni Mills, welcome to ReachMD XM 157, the channel for medical professionals.

Ms. MILLS:

Thank you.

Mr. JAPSEN:

So, the medical home, it is in concept that more and more people should be hearing about not only in the healthcare industry but general consumers as well. Tell us about what BlueCross and Shield Association pushes in regard to the medical home and if you could, for our listeners who don't know tell us exactly what a medical home is?

Ms. MILLS:

Okay. Well, you know, currently the US Healthcare System is plagued by inconsistent quality, inadequate access, and excessive cost borne by employer groups and individually. Additionally, there is a problem with primary care recruitment and retention, you know, according to the common well fund, the US has 87 PCPs for at least 100,000 lives and continues to trend downward. We have got an aging population and an increase in prevalence in chronic diseases, a system that emphasizes episodic treatments for acute care and more care rather than better care, decreased patient provider and employer satisfaction. So, the optimal scenario of healthcare lies beyond, far beyond the statistical right now and to bridge the gap, we need to align stake holder groups to reinvent the way healthcare is practiced, financed, and even consumed. I think right now, the stars are aligned for the patient center home. The concept of a medical home is not really new, I mean it was initially introduced by the American Academy of Pediatrics in 1967, and at that point, was referred to the central location for a child’s medical record, you know, it is, it was particularly important for children with special needs. This concept is evolved over time from central medical records to a method of providing comprehensive primary care for children and it is now actually, you know, working its way to the adult care. The American College of Physicians, ACP, the American Academy of Family Physicians, AAFP, and the American Osteopathic Association, AOA, actually in March of last yearend introduced some joint principles for those patients sent to medical home and joint principles really are around a personal physician that each patient has an ongoing relationship with a personal physician, a physician directed in medical practice, the physician leads the team of individuals to the medical practice and takes collective responsibility for that patient. It is a whole patient orientation, you know, I am the patient and I have a doctor that will listen to me. It is care coordination and integration across all the elements of a very complex healthcare system, you know, you got hospitals, you got health home agencies, you got nursing homes, you have got, you know, all kinds of facilities and all kinds of places that take care of you but who is really your advocate, who is your patient and you know it is really about patients having access to care throughout the system and we know that in using evidence based guidelines, so who is, you know, who is, can I take a bag of medicine that I take to my primary care and can he tell me the drug interactions. Instead of me talking to my cardiologist, talking to my pulmonologist, talking to everybody else who would know what they are giving me but who is coordinating this care for me and also we realize that, you know, this enhanced care is going to need to be paid appropriately. It is not the 7-minute office visit in the doctor's office because he or she needs to spend time with you. They need to, you know, recognize that they are going to add value and the payment structure should be based on that kind of value.

Mr. JAPSEN:

Is there anything for physicians listening or even consumers that a physician needs to do if they are sitting and they are saying, you know what, I have a practice with 4000 patients, I am really busy, I don't even really have time to do some other things but are there simple things they could do, I mean is that as simple as having them on an e-mail list and e-mailing them every 6 months saying, hey come and see me or how would you any sort of basic tips you would give a physician on this?

Ms. MILLS:

Transformation of the practice is not easy and it is going to be, you know, we have a number of pilots throughout the United States, some multi-payers , stake holders, some within the Blue plans themselves and the road is going to be bumpy because it is not, I can setup an e-mail list, it's, you know, using an electronic medical records is one of the first key steps, you know, that is not always easy because you have to get the right record, you have to transform your practice. It doesn't stop the day the record comes in. All that information has to get on but there are groups our there that really are trying to help. I am going to suggest that some of your listeners even go to bcbs.com and click under the resources. There is a button on the top, you know, it's a publically available web site and it gives a lots of information about the patients in a medical home. It gives, it will let you actually go to a collaborative that has been formed called the Patient Center Primary Care Collaborative and that is a coalition of major employers, consumer groups, organizations representing primary care and other stake holders who have joined to advance the patient center home, the collaborative believes this implement the patient center home will improve the health of patients and healthcare delivery and actually studies are just started to come through Barbara Starfields from John Hopkins studies that showed the populations, which utilized primary care experience, lower healthcare cost, lower medicare spending, lower resource input, lower utilization and get better quality of care. So, it will be different. It is going to be different in central New York City and in rural North Dakota, you know, and how they implement and what they do. We have a really good plan in North Dakota, very rural 7-practice doctors who have a great patient-centered medical home, way different, you know, they have lowered, they have lowered blood results, they have lowered cost of care and they all have better quality of care but that might not work in downtown Chicago.

Mr. JAPSEN:

Tell me about some of these pilots and how they can look for these and what they do?

Ms. MILLS:

The patient center primary care collaborative actually has an entire listing of those states and those collaborators in different states that are doing some pilots and some demonstration. CMS also plans on doing some pilots but I think it's a year or so out, but I can tell you that there are a number of states listed in here that Medicaid Centers are doing that a number of different states in Vermont as initiatives. BlueCross, BlueShield of Michigan has a pilot that they are looking at infrastructure to improve care in poor chronic illnesses and they have established a pool based on 5% of the physicians payment. Right in that listing in the patient’s guide are the contact information who they could contact if they are in their state, what they need to do, what kind of pilot that they are establishing and, you know, who is in the collaborative or if it's a single payer who is in the single payer state. So, that would be an excellent source for depending upon where your physicians would like to look.

Mr. JAPSEN:

You know, one of the issues is often reimbursement and payment and so forth. I mean, is it a good idea for the physician if they are in contract negotiations or if their group is in contract negotiations with the health insurance company to ask questions and say, hey, do you have any pilot programs? Do you have any efforts going on that would help me pay work for medical records or get me to the medical home concept?

Ms. MILLS:

I think that, you know, may be it is not during the negotiations but may be they want to contract their vendor and their insurer and ask them, you know, what is that they are doing, what kind of, how can they help, what can they do to? They also may want to contact their physician societies, the AAFP, ACP, AOA, all have a lot of initiatives going on to help with resource tools that these primary care physicians may use. They may be looking at electronic medical records and what they could use and they may find help from the healthcare, from the health plan.

Mr. JAPSEN:

Yes, we are talking about the medical home about each patient having a relationship with their doctor and if I could ask what is the idea of medical home, I mean from an insurance company’s perspective, is that, is it as simple as making sure your patient comes to the doctor once a year or is it something that the insurers want to see from a physician or what would you say that would be?

Ms. MILLS:

I think a real medical home would be where patients and doctors create an atmosphere of, you know, coordination care, better collaboration, getting better outcomes, you know, getting the right care done right the first time, making sure that somebody knows me and what I need. You know, they are not, they are not a gatekeeper. They are care facilitator, their goal is to facilitate and integrate specialty care. So, whatever methodology they need to use, I mean, If they can use electronic medical record, you know, that is a good support they need to coordinate care, they need to be accountable and accountable for longitudinal care, accountable for , both sides, I mean this is all parties are accountable. The patient is accountable. The provider is accountable. The importer is accountable. I mean all of us are accountable for a shared goal of better outcomes for their patient.

Mr. JAPSEN:

And when it comes to be uninsured and of course that problem just does not go, you know, where the folks who have no health benefits, what does the BlueCross and BlueShield Association have for those folks in the line of in fostering a medical home.

Ms. MILLS:

There are some Medicaid medical homes that in some states are doing. There is a terrific group, Medicaid Connect Care Choice Program in Rhode Island that is looking at the Medicaid people for those uninsured who are eligible for Medicaid to do that. You know, the uninsured is a very complicated issue and who is uninsured and why would make a difference, but certainly in the Medicaid population and in some of the others, there is what is available and certainly as more people adopt the medical home that doctor is not going to practice any differently for an uninsured person as they are going to practice for the insured. So, it is about transforming the mindset in the healthcare of the patient and the doctor.

Mr. JAPSEN:

And of course, if it is a success, there might be more money to cover more people. With that, I would like to thank Toni Mills with the BlueCross and BlueShield Association who has been our guest.

I am Bruce Japsen of the Chicago Tribune. I have been your host at the clinician's roundtable on ReachMD XM 157, the channel for medical professionals. If you have comments or suggestions, please call us at 888-MDXM157 and I would like to thank you today for listening.

You have been listening to public health policy in America, a special ReachMD XM 157 interview series with our nation's top leaders in public health. This month, ReachMD XM 157 will be discussing the many issues challenging public health policy in America. For a complete schedule of guests and programming information, visit us at reachmd.com.