Stateline Story

States Advance With Patient-Centered Care

After Pennsylvania rolled out a new program that targeted care for the chronically ill last May, one of the first things the four doctors who run Mt. Airy Family Practice learned was that their diabetic patients weren't doing as well as they thought.

As part of the program, the Philadelphia doctors put their 450 diabetic patients' records online, including the date of their last visit and their A1C count, a measure of blood sugar. If it's too high, it means a patient's disease isn't being managed well.

The registry showed that more patients than expected had high A1C counts. "The better-controlled patients were coming in more often for checkups, so we thought, 'oh, we're doing pretty good,'" Dr. Thomas Lyon said. "The less well-controlled patients were in less frequently, so we didn't think about them as much." And those patients were having problems.

Mt. Airy then scheduled more frequent visits for the diabetics with high A1C counts until their blood sugar dropped. That was just one of the initiative's benefits.

At least 20 states run some form of this program, known in health care circles as a "medical home." By promoting disease management, patient education, electronic records and more personal primary care, the programs are intended to improve care while cutting health care costs for patients with chronic illnesses, such as diabetes and asthma.

What's prevented are unnecessary emergency room visits, hospital readmissions, redundant and expensive tests, and serious procedures, such as amputations for diabetics.

Most of the state programs have launched over the last few years - although one of the first was started in 1998 in North Carolina - but the "medical homes" concept has emerged as a working model this year as President Obama pushes for widespread health care reform. Administration officials are talking not just about covering more people, but overhauling how health care is delivered to make it more efficient and less costly, along the lines of what some states are already doing.

"There are legions of stories of people who are just going back and forth in the system. The ideal would be to have a more centralized place, a health professional who would be helping them to manage their care," said Nancy-Ann DeParle, the head of the new White House Office of Health Reform, at a recent forum . "There are things that we can do to change the delivery system and move toward smarter care."

In the state-run programs, the primary care physician oversees a team with a variety of professions that can include nurses, case managers, nutritionists, wellness coordinators and psychologists. By coordinating ongoing care, the programs aim to change from the current system that relies on waiting for something to go wrong to one that focuses on prevention and improving long-term health.

The medical home format is similar to what some private insurers do for their clients with the help of disease management vendors, but "more hands-on," said Enrique Martinez-Vidal, director of State Coverage Initiatives , which monitors state efforts to expand insurance coverage. Most people with chronic conditions are managing them well, except for a subset that is "seeing 10 different hospitals, going to the hospital 50 times a year, filling out prescriptions that different doctors have written them. It's just terrible care coordination," he said.

Pennsylvania's initiative was launched at the behest of Gov. Ed Rendell (D) after the state reportedly spent in 2007 almost $4 billion in avoidable hospital costs just from four chronic diseases: asthma, diabetes, heart disease and lung disease. Nationwide, about 75 percent of all health care costs are attributable to people with chronic illnesses.

Pennsylvania is in the first year of a three-year program that its officials claim is the country's largest private-public chronic care collaborative. For now, 32 practices and some 150 medical workers in the southern parts of the state are working with 230,000 patients. By the end of the year, the collaborative will expand to other regions and will involve at least 550 doctors and 1.5 million patients.

One innovation of Pennsylvania's program is its funding: mostly from private insurers. The state pays just for training doctors on the program model, while insurance picks up the tab of paying doctors for their extra work, with about 15 insurers agreeing to finance the experiment in its three-year run. The state pays only when Medicaid patients, through managed-care organizations, participate in the program.

Switching to a medical home model means extra money for doctors who revamp how their practices operate. That strikes at what experts say is necessary for improving health care - giving doctors a reason to provide more care upfront.

For Mt. Airy, the additional money was a real incentive. Each doctor can earn about $45,000 extra a year for participating, Lyon said. The clinic already used part of that money to hire an extra medical assistant who updates the registry, ensures doctors have the correct information, and checks in with patients, particularly between regular visits, which the clinic is doing more of these days.

Because of the initiative, Mt. Airy also began evening group meetings to coach diabetics on how to better manage their disease. One of Lyon's patients who was struggling to control his diabetes attended three sessions in six weeks. At a recent visit, the doctor learned that for the first time in a year and a half, his patient had lost weight. Also, his blood pressure and blood sugar had fallen to ideal levels.

"He's deciding to respond to these diabetes classes," Lyon said. The state's program hasn't even been around a year yet, but "we're providing better care to our patients. …We're letting less slip by than we used to."

Besides Pennsylvania, the most-watched state-launched experiments are in North Carolina and Vermont.

North Carolina has one of the oldest and most successful programs ; in 2006, it saved the state more than $160 million . It first began operating in 1998, but went statewide only in 2005. The program, which initially focused on diabetes, asthma and heart failure, has 14 networks across the state, with 1,200 doctors' offices serving almost 890,000 Medicaid patients.

The state relies heavily on case managers who make sure patients follow their doctors' orders, address personal problems that could interfere with their health and help patients navigate the health care system.

Sometimes this requires a visit to patients' homes. For asthmatic children, case managers might even visit a school to show a teacher how to manage a student's medications, said Chris Collins, the acting deputy director of the Office of Rural Health and Community Care."They'll make sure everybody's on the same page," she said.

The Community Care program has been so successful that last year the Legislature ordered the program to expand in October to include Medicaid patients with multiple chronic illnesses, which is estimated to save another $29 million.

Vermont Gov. Jim Douglas (R) unveiled his program, Blueprint for Health , in 2006. Currently it's operating in only two communities, but is scheduled to go statewide by 2012 and serve all 620,000 residents.

Each pilot program has teams of case managers, but along with chronic care, the program also promotes prevention strategies for whole communities. For example, the plan looks at whether a community has enough walking paths or easy access to fruits and vegetables in winter. So far more than 800 people have attended free six-week Healthy Living workshops held by the state.

Like Pennsylvania, Vermont's program includes private help; it's funded by the state's three main private insurers, the Medicaid program and the state, which pays for Medicare patients to participate because the federal program doesn't financially support these programs. In 2006, the Legislature mandated that private insurers help pay for the program for at least two years. Whether they continue to pay after that will depend on the program's success.

"We need to show that patients are showing better health care quality and need to demonstrate whether this is indeed fiscally sound. If it is, we've been told by insurers that they'd help pay," said Dr. Lisa Dulsky Watkins,the Blueprint's assistant director.

Tags: Health