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Reform Update: New care model targets high-risk patients with comprehensive-care docs

By Andis Robeznieks
Posted: May 12, 2014 - 4:00 pm ET

New models of healthcare delivery emphasize team-based coordinated care, but a new idea being tested at the University of Chicago proposes a new, somewhat old-fashioned concept targeting high-risk patients: the comprehensive-care physician.

In a clinical trial funded by the CMS Innovation Center, University of Chicago physicians are assigned patients identified as high risk for hospitalization and follow them through inpatient, outpatient and home-care settings.

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“The traditional internist can no longer do that job,” said Dr. David Meltzer, chief of the University of Chicago section of hospital medicine. “They just don't have enough hospitalized patients to make it worthwhile.”

Meltzer and Dr. Gregory Ruhnke, an assistant professor with the University of Chicago section on hospital medicine, summarized their program in a Health Affairs report, but Meltzer said data on the effectiveness of the program won't be available until 2016.

“The reason why we published now is to get the idea out there,” he said. “We're still enrolling patients.”

The program's key outcome measures are self-rated health status, limitations on activities of daily living, and mortality. Its economic success will be judged by the cost of care to Medicare.

While many argue that coordinated care depends on clinical teams with nurses, nurse practitioners, physician assistants and other nonphysician professionals empowered to “practice at the top of their license,” Meltzer warns that this is not always the best way.

“I think it's an iconoclastic perspective,” Meltzer said. Team-based care, he said may add fragmentation and communication errors during patient handoffs.

Under the University of Chicago's “comprehensive-care physician model,” five doctors visit patients in the hospital in the morning, while nurses and other professionals provide noncomplex care at the physicians' clinic. One doctor is assigned afternoon rounds and weekend call. Hospitalists, meanwhile, may see patients on night rounds.

The physicians are each assigned panels of 200 patients expected to average about 10 hospital days a year. They are assisted by a clinic coordinator, registered nurse, nurse practitioner and a social worker.

Meltzer emphasized that the concept was “not in any way a repudiation of hospitalists,” but a “best of both worlds” model that combines the duties of a general internist and a hospital medicine specialist.

“Providing these physicians with a high volume of inpatients and locating their clinics in or near the hospital can allow them to offer many of the same benefits that hospitalists provide in terms of inpatient experience and physical presence and to offer the additional benefit of continuity across settings and over time,” Meltzer and Ruhnke wrote in Health Affairs.

Minnesota nurse practitioner bill awaits governor's action

Nurse practitioners are still waiting to see if or when the governors of Connecticut and Minnesota will sign bills that will grant them the authority to practice with greater independence.

The Minnesota bill was passed by the state Legislature last week and sent to Gov. Mark Dayton. It calls for nurse practitioners to have 2,080 hours of training before they can practice independently, forbids them from identifying themselves as doctors, and doesn't permit them to interpret advanced diagnostic imaging, according to the Minnesota Medical Association.

“The final legislation is not what the MMA would draft, but we stopped contesting it after we reached the compromise,” Dave Renner, MMA's director of state and federal legislation, said in a news item on the MMA website.

While there has been no word about Dayton's intentions, Connecticut Gov. Dannel Malloy signed the bill in his state on May 8.

Nurse practitioners have had mixed success this spring. A bill advancing their independence was enacted in New York, vetoed by the governor in Nebraska, and died in the California and Florida legislatures.

Predicted doc shortages don't materialize

The physician shortages that many warned would materialize as millions of Americans gained coverage under Obamacare are a no-show so far.

There have been few reports of newly covered patients having significant trouble getting timely access to care, according to Kaiser Health News and USA Today.

The report notes some exceptions in areas of Colorado, Kentucky and Washington state. The reason, story suggests, is that many of the policies are just now taking effect. Also, severe weather this winter dissuaded many patients from seeking care, as noted in the first-quarter financial results for several healthcare companies.

Another possible factor: An estimated 5 million people who would have qualified for Medicaid under the healthcare law live in states that declined to expand their programs.

Correction: An earlier version of this story reported that Connecticut Gov. Dannel Malloy had yet to sign the bill regarding nurse practitioners. He signed it May 8.

Follow Andis Robeznieks on Twitter: @MHARobeznieks

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