In the depths of the Depression, former President Franklin Roosevelt called for “bold, persistent experimentation. It is common sense to take a method and try it. If it fails, admit it. But above all else, try something.”
The high cost and poor quality of American healthcare have made experimenting with new ways to deliver and pay for healthcare an imperative. These experiments were necessary before the new health reform law passed last year, and they are necessary regardless of what happens in Congress that might affect reform going forward. We cannot expect to slow down cost increases or get better outcomes by continuing on the path we are on.
The Robert Wood Johnson Foundation launched the Aligning Forces for Quality initiative, which I wrote about for
Modern Healthcare in October 2009, to help communities experiment with new approaches to lifting the quality of care. Rather than mending a broken healthcare system one clinic, one hospital or one disease condition at a time, as we had done with previous initiatives, Aligning Forces takes a community-based, systems approach. The multi-stakeholder alliances in each of the 17 communities our Aligning Forces program supports are working to measure the quality of local care and make that information public, help providers learn how to deliver better care, and engage patients in making informed choices about the care they receive.
As we enter the fifth year, the alliances are also moving into the realm of payment reform, starting with several promising patient-centered medical home pilots. To be sure, the medical home idea isn't unique to Aligning Forces. But Cincinnati's Dr. Robert Graham, an early proponent of the medical home, said what differentiates the Aligning Forces medical home experiments is their strong ties to measurement and reporting. “Public reporting,” Graham said, “is what will get practices' attention.”
Graham's own Health Improvement Collaborative of Greater Cincinnati is among the Aligning Forces communities that have opened their medical home experiment to the scrutiny of public reports. The 18-month old pilot of 11 internal and family medicine practices serves nearly 100,000 patients. All 11 have received recognition from the National Committee for Quality Assurance, which helped get buy-in from insurers who wanted to ensure the quality of care from a third party. More importantly, patients are getting more deeply engaged with their healthcare team. Participating practices have set aside specified slots of time for walk-in appointments with physicians and moved toward team-based care, utilizing the training of the entire staff to manage their patients' cases. In return, the practices receive case management fees on top of their usual fees.
Unlike urban Cincinnati, Maine is a sparsely populated state with only 450 primary-care practices. With 26 participating practices (22 adult and 4 pediatric), Maine's Quality Counts medical home pilot is one of the most robust in the country. Most of the major insurers are participating in a new three-tiered payment structure. It includes a “per member, per month” care management fee, continued fee-for-service payments as well as incentives for high-quality performance. Recently, the federal government chose Maine as one of only eight states to test the medical home model for Medicare enrollees.
What's paramount to Dr. Lisa Letourneau of Quality Counts is “culture change, leadership and commitment. The professional motivation is more important then the financial motivation.”
The
P2 Collaborative of Western New York, the alliance operating in Western New York, has a distinctive twist on the medical home. The pilot is a unique hybrid of a program first developed for the United Kingdom's U.K.'s National Health Service and the type of cooperative agricultural extension service that is familiar to rural areas of New York. Called practice-enhancement associates (PEA), these clinical assistants—many of them registered nurses—bring improvement initiatives to primary care in the Buffalo area. PEAs work for more than one practice, are paid by the practices and interact with patients on behalf of the practice. They follow up with patients to make sure, for example, that patients with diabetes understand how to take medication and use a glucometer for home monitoring.
When it launches in 2011, the Washington State Multi-Payer Medical Home Reimbursement Pilot will offer an additional monthly fee—similar to Maine's care management fee—to reward primary-care practices for providing more coordinated, quality care. Doctors' offices will be compensated more if they achieve specific, targeted outcomes, such as increasing flexible access to care, tracking and monitoring chronic conditions and doing preventive outreach or follow-up planning. Participating practices will also share savings if they can reduce potentially avoidable emergency room and hospital admissions while maintaining quality care for patients with chronic conditions.
The various medical home pilots, including those being conducted in the 17 Aligning Forces communities, are designed to determine whether integrating various incentives for better healthcare quality can push improvements forward at a faster and more substantial rate than would be expected with any one of the individual initiatives alone. Whether these experiments succeed or fail, they speak to the goals of a reformed healthcare system: greater transparency, improved quality as reflected in efforts to coordinate care, keeping people out of the hospital and improving communications with patients, plus lower costs.
Health reform is a national objective, but as these various medical home experiments illustrate, it will unfold in many different ways, one community at a time.
Anne Weiss, a senior program officer, directs the Robert Wood Johnson Foundation's quality/equality healthcare team.
