New Maryland health program promotes care for the whole patient

Every weekday, nurse Jill Ross telephones some of her sickest patients. On this particular morning, she is asking breast cancer patient Renita Mock when her double mastectomy is scheduled. The conversation quickly veers to Mock’s stress over the operation.

As someone with diabetes, hypertension and a host of other illnesses, Mock, 52, is considered too high-risk for reconstructive surgery, and she’s struggling with the prospect of losing her breasts. She asks for help in finding a therapist.

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Ross promises to provide her with names. She also tells Mock that she’ll be calling regularly “to see how you’re doing, if you saw a specialist, if your medication’s changed, kinda seeing what’s going on with you.”

Thank you so much, Mock replies.

“It’s a lot going on, and it’s stressful,” Ross adds. “But you know what? We can get through it.”

These calls to patients are part of a new approach to primary medical care that Maryland is testing across the state. Instead of a doctor seeing patients mostly when they’re sick — and the physician is getting paid for that visit or service — this program gives financial rewards to practices that use a team of doctors, nurses and other staff to treat the whole person on a continuing basis, not just for one illness. The team focuses on patients with chronic conditions, develops individual care plans, and coordinates with specialists. Emphasis is on prevention and comprehensive care.

For a patient, it is like having a doctor’s office that acts like mom — with nags and nudges designed to promote better health.

The state initiative is among dozens of public and private experiments across the country that are trying to fundamentally change the way doctors practice medicine. Federal policymakers are watching closely to see whether the strategy can improve care and reduce costs, one of the pillars of the health-care overhaul law.

Early experiments suggests that definitive results will take substantial time and investment. But, experts say, the concept holds promise for rescuing the country’s historically underfunded and undervalued primary care system.

Primary care doctors will be in even greater demand as the country approaches 2014, when the health-care law is expected to expand insurance coverage to millions more Americans.

For patients such as Mock, the extra support is welcome. She likes the idea of one office being in charge of her health. Especially now.

“When [the surgeon] told me I might have no breasts, well, that threw me for a loop,” Mock said in an interview later. “I was holding back tears, then I just broke down. . . . When you get sick, you think, ‘How do I help myself?’ ”

‘Value, not . . . volume’

Coordinating care is part of Jill Ross’s new duties at MedPeds, an internal medicine, family medicine and pediatrics practice in Laurel. It is one of 52 primary care practices chosen by state health officials from about 200 applications to take part in the Maryland program, which began in May and will run for three years. About 245,000 patients are in the program.

All five of the state’s largest commercial health insurance plans — CareFirst, Cigna, Aetna, Coventry and United Healthcare — as well as the state Medicaid program are joining to provide about $6 million a year to practices for additional staff, training and technology upgrades. Despite tight budgets and cost pressures, the state and the insurance companies are betting that these upfront investments will save money and improve care in the long run.

The new payments to the practices are in addition to fees doctors currently receive from insurers or Medicaid for office visits and other services. Practices also will receive 50 percent of any savings in total patient costs resulting from, for example, fewer avoidable hospital admissions and emergency room visits.

In return, practices have to meet numerous quality measures. They must have extra office hours and same-day appointments for urgent-care patients. The prac­tices must use electronic health records to manage patients with chronic conditions, such as diabetes. And they must have a team to coordinate patient care, including tracking referrals to specialists and updating medications.

It’s a big change from how it works in many practices now.

Doctors are “scattered and stretched so thin and chasing these tiny [reimbursement] rates for little increments of time, so they can’t spend time with their sickest patients to make sure they’re managed well,” said Joshua Sharfstein, Maryland’s secretary of health and mental hygiene.

Under the experimental approach, formally known as the patient-centered medical home, “we’re paying for value, not for volume,” he said.

Those patients who need more monitoring typically have multiple conditions. They are assigned to care coordinators like Ross, who may follow up with a diabetic to monitor glucose levels and control other conditions, such as high cholesterol and high blood pressure, so the diabetes doesn’t get out of control.

“If their blood sugars are off the wall and you’re calling them monthly, you can catch that before their three-month or six-month visit and really decrease the chances of something happening and them being hospitalized,” Ross explains.

Reaching out to patients on the phone or through e-mail reminders is something insurance plans have tried in the past. Before Ross joined the MedPeds practice, she did essentially the same job for an insurance plan.

But the trust level is not the same.

“People respond to their doctor differently than an insurance company nurse,” said Seth Eaton, one of the doctors at MedPeds. “We have a better chance of getting them to make changes in lifestyle issues.”

Changing behavior

The new approach is extremely labor-intensive for doctors and staff. In addition to face-to-face visits, they need to schedule phone time for patients, post lab results that can be viewed securely on the Web, track reports from specialists and follow up on hospital visits, among other duties.

“Clinicians have never really put effort into care coordination because we were never paid to do this,” Eaton said.

The program payments to the practice will total about $300,000 this year. That includes money for technology upgrades, additional staff and more compensation for doctors and staff, he said.

It’s not clear yet what level of financial incentive is needed to produce results, according to Bruce Landon, a professor of health-care policy and medicine at Harvard Medical School.

CareFirst BlueCross Blue­Shield, the Washington region’s largest health insurance plan, began a medical home program this year that now includes 3,300 doctors and nurse practitioners in the District, Maryland and northern Virginia. Chet Burrell, CareFirst’s chief executive officer, said the plan offers greater clinical support and heftier incentives than the Maryland program to doctors who sign up.

But the Maryland program has participation from all the large carriers, and that sends a strong message “that they will pay extra for care coordination to promote behavior change and health of the whole person,” said Kevin Grumbach, chair of the family and community medicine department at the University of California in San Francisco.

“It’s hard for practices to rethink change” if only a portion of their patients are affected, he added.

Ultimately, the goal is to change patient behavior, which might be the greatest challenge.

At the Waldorf office of Shah Associates, care coordinator Mary Levy is responsible for monitoring 48 high-risk patients. On a recent weekday, her to-call list included a diabetic man in his 60s who was overdue for his three-month blood sugar test and a 72-year-old woman with a serious lung disease who frequently goes to the emergency room when she has shortness of breath.

In the man’s case, “I just think he doesn’t want to come,” she said. “I will call him at home.”

In the woman’s case, Levy is coaching her to use the devices she has at home that turn her medication into a breathable mist. They are the same, Levy says, as what the hospital uses.

Even patients who don’t need the extra level of monitoring say they benefit from the new approach.

Bernadette Rappold’s internist is Angela Marshall, a solo practitioner in Silver Spring. Rappold has diabetes and other chronic health issues. She likes that the practice uses well-organized electronic records and that Marshall and her physician’s assistants are easily reachable outside traditional office hours. Most important, she likes how they treat patients.

It’s very different, she said, from a recent experience with a specialist who lectured her about her weight and made her feel ashamed. “After the appointment, I cried,” Rappold said.

Marshall’s practice has sent
e-mails offering a medically moni­tored weight-loss program at the doctor’s office. Rappold said the approach is nonjudgmental, offered in the spirit that “they’re really trying to promote your health.”

The logistics of the weight-loss program proved too difficult, but the reminder got Rappold back on Weight Watchers.

 
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