Ruby Holmes (pictured) got tired of having a different doctor every six months after she moved to New Haven from Mississippi, where she always saw her own doctor. Finally she found a “medical home” at the Hill Health Center, and she’s been satisfied ever since.
A “medical home” is not a hospital, nursing home or clinic. It’s a concept of providing consistent, high-quality medical care to all patients. And it’s had a dramatic impact on reducing racial and ethnic disparities in health care.
Holmes, who lives in West Haven, said after she moved to New Haven in 1977, for many years she had a different doctor “every six months or so. I guess they’d be in school or something, and they’d leave and go to Chicago or someplace.”
Then in 1984, Gary Spinner finished his training as a physician associate and went to work at the Hill Health Center. Ruby Holmes was one of his first patients. She’s still his patient. “If I have the same doctor,” she said emphatically, “I don’t have to tell them this and that, because they already know. I’m from Mississippi and we had the same doctor all the time, unless one died or something. Gary’s real, real nice and I’m real, real crazy about him.”
The feeling’s mutual. Spinner, who is now the chief operating officer at the health center, still sees patients, Holmes among them.
“A medical home is essential to promote a relationship between a health care provider and a patient,” he said in a phone interview. “There must be continuity and trust. It’s not sufficient to just be a good diagnostician and be able to write a prescription. Trust is necessary for a patient to follow a treatment plan. It’s important that patients be able to ask questions of their provider. A good relationship means give and take between patient and provider to come up with a treatment plan that will be successful, especially for people with chronic illness.”
Ruby Holmes fits the bill — she has heart disease, high blood pressure and diabetes.
The concept of a medical home was born in the 1960s. It “originally meant the physical place at which the multiple components of the health record of a child with special health care needs was kept — so it was one place where a child could be cared for holistically,” said Dr. Richard Antonelli, a pediatrician in Hartford who advises health providers throughout the country on the medical home concept and helped write the American Academy of Pediatrics statement on medical home.
The definition has since expanded to cover all patients — children and adults, those with special needs and those who just need basic care. When patients have insurance coverage and equal access to a medical home — defined as “a health care setting that provides patients with timely, well-organized care, and enhanced access to providers” — a 2006 survey from the Commonwealth Fund found that racial and ethnic disparities in access and quality are reduced or even eliminated.
The report states, “When adults have a medical home, their access to needed care, receipt of routine preventive screenings, and management of chronic conditions improve substantially.
“The survey found that rates of cholesterol, breast cancer, and prostate screening are higher among adults who receive patient reminders. When minority patients have medical homes, they are just as likely as whites to receive these reminders. The results suggest that all providers should take steps to create medical homes for patients. Community health centers and other public clinics, in particular, should be supported in their efforts to build medical homes for all patients.”
Indicators (though not a comprehensive measure) of a medical home are that patients have a regular doctor; easy access to that provider by phone; availability on evenings and weekends; and office visits that are well organized and on schedule. Twenty-seven percent of adults (18 – 64) surveyed answered Yes to all four indicators.
In addition, Ann Beal, the researcher who conducted the Commonwealth Fund study (and who is a pediatrician by training) said other questions must be answered as well: “Are you treated with respect? Given an action plan? Getting patient education? Shown how to manage your condition at home?” She said when these are answered in the affirmative, racial disparities start to disappear.
The availability of chronic, acute and preventive care is also key to providing good health care and reducing disparities.
The New York Times ran a front-page story recently that touted saving money by paying doctors more. That seeming contradiction really wasn’t one, because, the article explained, if doctors and other providers could be paid to spend more time with patients, they would discover problems that could be treated before they erupted into crises that required more intensive care and expense. Providers would also have time to do more preventive care.
How does having a medical home relate to health care financing? “It relates because you get what you pay for,” Beal said. “If you want fragmented care, that’s what you get under existing fee for service, where you pay for each visit (each intervention) as if it’s a separate thing, like a widget. But if you want medical providers to answer their phone calls and emails and discuss with other colleagues how best to treat a patient, and if you want e‑medical records and after-hours care, then you need to reimburse for that as well. Primary care societies are saying, ‘Pay me $2 – 3 more each month to provide those services, and also pay me for the outcome.’
“There’s a growing crisis in primary care where fewer and fewer medical students are choosing it,” Beal continued. “It’s one of the lowest paid specialties. Medical home creates a system where doctors can care for patients the way they really want to.” In fact, only 7 percent of medical students are choosing primary care (pediatrics and internal medicine). Why it’s even called a “specialty” is a mystery.
There’s a lot of interest in the concept in the medical community, Beal said, but added, “We’re not hearing a groundswell of interest from patients themselves. I think that’s a problem with marketing, because if you ask patients those questions [above], they say yes. We need more recognition from the public that that’s what a medical home is.”
As a large company buying health care "we have discovered the enemy it is us" -- they way we buy the way we pay has disintermediated the doctor patient relationship -- The way we no buy care for our employees allow me to buy a dare good amputation for my diabetic but does not empower the kind of relationship my employees and heir families needs with their doctor to have the robust prevention and primary care that would prevent them from needing an amputation. And, it sure as heck does not allow me the kind of relationship that prevents my patient from getting diabetes in the first place. The value is placed on the person trained to provide the amputation not on the comprehensive primary care provider that prevents the disease from ever happening. It values the hospital bed being occupied not the patient being whole and in good health. It encourages our professionals who should be healers to milk the system to provide in many many case toxic care.
This is a form of violence it is unacceptable, it is immoral, it is unethical we loss a 747 load of patients every day, we are dead last 19 out of 19 developed economies in the value health care brings our patient in the USA.
Although we tend to focus on the problems we face, there are reasons for a great deal of optimism-optimism due to the opportunities we have to improve and redesign care. Medical practice redesign is happening today. It is taking hold and has become a movement that is gaining momentum. We have the tools today the IT to support integration We the large employers for the first time are at the table with the national health benefit companies and primary care professional societies. Let's seize this opportunity and make the fundamental changes we have been asking for as large employers. Let support the providers of comprehensive integrated care. Let change the covenant between the buyer and provider.
Paul Grundy Directory Healthcare Transformation IBM and chairman of the Patient Centered Primary Care collaboratives www.PCPCC.net