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Published August 09, 2010, 12:00 AM

Doctors in Demand: Care model could cure industry ills

‘Medical home’ implements team approach
It’s being touted by leading medical organizations as a solution to rising health care costs and the shortage of primary care physicians. And it’s working its way into North Dakota.

By: Emily Hartley, INFORUM

It’s being touted by leading medical organizations as a solution to rising health care costs and the shortage of primary care physicians. And it’s working its way into North Dakota.

Innovis Health, like clinics across the country, is moving to a new model of primary care called the patient-centered medical home, or PCMH.

The model works like this: A physician leads a team of mid-levels (nurse practitioners and physician assistants) and nurses. One team member sees a patient based on the complexity of the patient’s problem, and the whole team communicates to stay informed about a patient’s care.

The medical home concept, which has been used to manage chronic illnesses in the past, has only become a popular option in primary care over the past few years. Still, providers said early results are encouraging, showing a decreased number of expensive visits to hospitals and emergency rooms thanks to higher quality outcomes, which cuts down on costs.

“The way we’ve delivered care is just not working, as you can see from the health care costs,” said Dr. Richard Vetter, chief of the medical service line at Innovis Health and one of 11 family practice physicians currently implementing the PCMH model. Four internal medicine physicians are also involved.

Using mid-levels to see patients previously seen by doctors also helps deal with a growing shortage of primary care physicians. The number of mid-levels has been on the rise, partly because the positions require less schooling – and incur less debt – than physicians.

Vetter said Innovis had a “handful” of mid-levels five years ago, but today, the system employs around 50. At Sanford, which uses medical homes for chronic illnesses and high risk pediatrics, the number has climbed to 147 mid-levels in the Fargo region. “We realized that mid-levels can play a role there and see less-acute patients for reduced cost,” Vetter said.

Innovis began discussing the concept last summer and implemented some changes in January, but they said it will take three to five years to complete the process.

For now, the hope is that the model will cure the industry’s ills relating to cost, access and quality of care.

“This seems to be the vehicle that, at least the preliminary stuff says, gets you down that road,” Vetter said.

Change is coming

Innovis’ take at the concept, Patient- and Family-Centered Care, also focuses on getting patients and their families more involved before, during and after their visits.

In January, patients began receiving a list of medications to review before appointments, which many took home as quick reference tools.

“Some patients really appreciated it. It gave them some more direction, and it helped their family members,” said Jane Skalsky, manager of Innovis’ Patient- and Family-Centered Care.

As more plan aspects are implemented, Vetter said patients will meet new changes, including visits with a mid-level rather than a physician.

Vetter and Wanda Hanson, manager of quality and chronic disease at Sanford, both called the medical home a “cultural change,” with physicians delegating duties or control in the team-based care.

Exactly what kind of resources Innovis’ overhaul will require has yet to be determined, but a pilot site at the South University clinic has increased its nursing staff by half while trying to figure out logistics. Members of Innovis’ project committee said the possibilities for Patient- and Family-Centered Care are endless.

Eventually, patients could fill out information online and get lab work before visits to leave more time for discussion at appointments. Technology could also bring online visits or conferencing and, ultimately, the ability to take vital statistics from a patient’s home.

Medical home money

The PCMH concept is moving into the eastern part of North Dakota thanks to its eastern neighbor. Minnesota has established itself as a forerunner in the concept.

The Minnesota Department of Health offers certification for “health care homes,” its version of a medical home, and the Minnesota Legislature recently took steps to ensure reimbursement from insurance companies for certified homes.

With incentives popping up in Minnesota, Innovis hopes to gain certification to secure reimbursement for its patients. Hanson said Sanford is “looking at the feasibility” of applying for certification in Minnesota, though they would use the concept more for chronic care management than for primary care.

Blue Cross Blue Shield of North Dakota launched a medical home pilot program with the former MeritCare Health Systems, now Sanford Health, in 2005 for diabetes, and they’re now working on ways to help in primary care.

The road to success?

The PCMH model is not without skeptics.

Some fear patient-physician relationships could be harmed if patients see different team members, and the cost of implementing the model in comparison with its savings is unclear.

A study of North Carolina’s system shows the model saving the state’s Medicaid more than $500 million from 2003 to 2007.

However, a 26-month study of 36 PCMH demonstration projects released in June concluded the model had “modest impact on quality of care and no improvement in patient-rated outcomes” and declared the process of switching to the new model “a complex endeavor that requires substantial time, energy and attention to potential trade-offs.”

The study acknowledged it is difficult to determine effectiveness in such a short time, and most medical homes take longer than 26 months to get started.

In any case, Innovis officials are confident in the concept, having recently created a program manager to help expand to all of their locations by 2011. Moving forward, they are tracking access to care, patient satisfaction and outcomes for the primary care project, and more data will be available a year from now.

Until then, they say they hope the project will prove to be the reliever of cost and physician shortage burdens that it appears to be.


Readers can reach Forum reporter Emily Hartley at (701) 235-7311.

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