As the smallest in size and fourth-least densely populated states, respectively, Rhode Island and North Dakota dont often find themselves leading the rest of the union. But both are in front of the pack when it comes to promoting the patient-centered medical home concept.
According to medical home advocates, the concept is designed to maximize chronic care, prevention and wellness while compensating primary-care physicians for care coordination and counseling and education done outside of the typical office visits, such as via telephone or e-mail. There are at least 22 medical home pilot projects in some stage of implementation, according to the Patient Centered Primary Care Collaborative, a coalition of providers, employers, consumer groups, unions and others, but officials in North Dakota and Rhode Island say their programs are the only ones that are statewide in scope.
In addition to being statewide, the Rhode Island Chronic Care Sustainability Initiative, which launched Oct. 1, stands out because it involves the states Medicaid program as well as its three largest commercial payers. Rhode Island Health Insurance Commissioner Christopher Koller said that, because of a 2004 state law, health plans are now legislatively mandated to work toward improving healthcare affordability, accessibility and quality.
It creates a different conversation than in other places, Koller said. The state holds insurance companies accountable for making efforts toward affordability, and thats what makes this effort possible.
The big payers in the stateBlue Cross and Blue Shield of Rhode Island, Medicaid, Neighborhood Health Plan of Rhode Island and UnitedHealthcare of New Englandhave agreed to pay a $3 per member per month fee for care coordination as well as pay for the services of a care-management nurse at the five practices participating in the pilot.
Insurance industry officials think the concept may be successful. The main advantage is that, over the years, a lot of doctors have complained about pay-for-performance programs that involve only one payer because they dont want to treat their patients with one plan different than the others, said Gus Manocchia, chief medical officer at the Rhode Island Blues.
Overall, were hoping doctor satisfaction will be better and their reimbursement will go up, said Neal Galinko, UnitedHealthcare of New England senior medical director, who added that savings are expected from fewer hospital readmissions, shorter lengths of stay, and fewer emergency department visits. Were pretty confident that, with more care coordination and integration, costs will go down.
Scheduled to last two years, the pilot includes five practices who agreed to conform to the standards required by the National Committee for Quality Assurance, receive special chronic-care training, educate patients on their condition and treatment, and do performance reporting on quality measures for coronary artery disease, diabetes and depression (See Commentary on p. 20, also Oct. 20, p. 36).
Galinko also said that measures were chosen because of the prevalence of the conditions and the wide acceptance of the standard treatment measurements for those conditions.
But while Rhode Island trumpets the start of its statewide pilot, North Dakota is set to launch its statewide program Jan. 1, 2009. Everyone is just doing pilots, the difference in North Dakota is that theyve already done a two-year pilot, so what theyre launching is the full-fledged implementation, said Heather McLarney, vice president of marketing for MDdatacor, the company whose information technology products are being used by Blue Cross and Blue Shield of North Dakota to facilitate its MediQHome quality program.
The pilot focused on diabetes care and, after two years, there was an estimated savings of $102,000 for the 192 patients involved.
Under the new program, physicians will be paid a $50 semiannual care-management fee for Blues members who are treated for coronary artery disease, diabetes or hypertension. Performance measures on those conditions as well as certain immunizations and screenings will be posted on the Web, said Jon Rice, the North Dakota Blues senior vice president and chief medical officer.
While official medical home definitions call for elements such as special attention to wellness and preventive medicine, and increased accessibility through the use of options such as same-day scheduling and e-mail consultations, Rice questioned whether this medical home infrastructure was necessary to achieve better outcomes and savings.
And though the program has the word home in its title and the term medical home is used in promotional and educational materials, Rice is not necessarily jumping on the bandwagon. The pilot was more of a disease-management program for diabetics, Rice said, while he described MediQHome as looking more like a quality-improvement project than a medical home project.
The honesty is appreciated by Terry McGeeney, president and chief executive officer of TransforMED, a for-profit, wholly owned subsidiary of the American Academy of Family Physicians that was mandated with supporting practices in becoming medical homes. For a practice to be called a medical home, it has to address all the patients in the practicenot just those with three or four diseases, he said. If you dont address the access issue, you might have an asthma program and check off all the boxes, butif a patient has an attack and cant get into your office and ends up in an emergency departmentyou have failed as a medical home.
Though he wouldnt name names, McGeeney said, Some payers with pay-for-performance programs just seem to rename them and call them a medical home.