Thursday, February 19, 2009

Medical homes, Paul Grundy - Interview with Edgar Mounib,MD, and Martin Kohn, MD, of IBM, on the Merits and Challenges of Setting up Medical Homes

Prelude: A team of people at IBM are preparing a White Paper on the Medical Home under the title of “The Medical Home, Why Now – and How?” It is an ambitious project and will be based on findings of the team itself and interviews with thought leaders. Recently I exchanged views with Drs. Edgar Mounib and Dr. Martin Kohn, on the whys, whats, and hows of Medical Homes. What follows are selected fragments of our lengthy exchange. Dr. Mounib appears in the early part of this interview but had to leave early to tend to a medical problem. To keep this interview within bounds, I have shortened, omitted, or altered some questions and answers.

Doctor Edgar Mounib

Q: Dr. Mounib, tell me about yourself.

A: My background is in public health. I trained as an infectious disease epidemiologist. I have worked as an epidemiologist, in hospitals, and in health insurance. I went back to school and got a MBA. I was medical director at BC BS of Massachusetts for a number of years. I have helped with the NCQA accreditation process. I lead the health care portion for the Institute for Business Value, IBM’s think tank, one of world’s largest think tanks.

We produce fresh, compelling stories about what’s happening in the health care industry. We tell these stories from the business perspective. It’s important to tell these stories to policymakers and CFOs. It’s not an IT story, but a more of a holistic story.

With medical homes, we hope to make a compelling story of “Why now, and how?” We think the evidence is overwhelmingly positive for Medical Homes for care providers and for other stakeholders as well– hospitals, health plans, and others and why they should take part. As we look at medical home projects across the country, we ask ourselves – What has worked and what hasn’t?

Doctor Martin Kohn (the rest of this interview are exchanges between Dr. Kohn and myself)

Q: Dr. Kohn, your background?

A: I am an ER physician, an engineer, and I have a degree in health policy management. I have been with IBM for 3 ½ years.

Q: That’s a formidable collection of degrees.

A: Yes, I thought, I have all these credentials, and I ought to do something with them. IBM gave me the opportunity. I work in the clinical transformation area, where we help physicians and health care organizations get maximum benefit from health information technologies. I am also working in the patient-centered medical home practice area. And I do epidemiological research in Hawthorne, New York, on artificial intelligence and its possible role in clinical decision making.

Q: Sounds to me like you’re a Renaissance man for IBM.

A: Either that or an incurable dilettante.

Why Medical Homes Now

Q: Why now?

A: Our primary care system is under duress. The shortage of primary care doctors is growing, and it’s growing fast. There’s also a decrease in job satisfaction, as doctors encounter more administrative complexities. There’s a reimbursement factor as well. We all agree primary care is critical to any health care system, whether it be in Spain, New Zealand, Denmark or the U.S.

Those are the key reasons for Why Now? Further, team care is important. Medical Homes differ from Pay-for-Performance and other initiatives. We think medical homes are a true advance in correcting flaws in the U.S. health care system and setting those flaws right.

The evidence is overwhelming that where primary care is pervasive , outcomes improve, costs go down, and satisfaction reigns. We believe in a Medical Home structure that supports primary care and patient relationships, and information systems that foster that bond and address the flaws in American health care – redundancies, duplications, and lack of wellness and prevention.

Q: So your White Paper is designed to convince policy makers and others that the Medical Home’s time has come?

A; Yes, but we don’t want to make this White Paper a rah-rah type of article. We want to make it realistic by interviewing people like yourself to get feedback about what’s likely to work.

Where the Medical Home is Now in Physicians’ Minds

Q: Let me tell you where I think you are now. A recent Healthleadersmedia survey of physician leaders gave the following picture (figures rounded).

Strongly positive, 6%
Slightly positive, 26%
Neutral, 60%
Slightly negative, 4%
Strongly negative, 4%

So 92% of physician leaders are either neutral or positive. That’s a good start. I don’t think there’s any organized resistance to Medical Homes.


I sense, however, and I talk to doctors all over the country, some skepticism.
One of these skepticisms is: Is the Medical Home just a super- or exalted gatekeeper model posing under a different name? What is your answer to that fear?

A: It’s an understandable fear. The distinction we’re making is to distinguish from “gatekeeper” is “gateway.” This is not a process based on denying access, but a process based on best practice and evidence-based medicine to make sure the patient gets what the patient needs and to avoid that which is not valuable.
Managed care denied access, but not based on quality or evidence. The Medical Home is a cooperative effort between doctor and patient to get access to care the patient needs and to protect the patient from care the patient doesn’t need.

American Culture

Q: Another one of your problems, as I see it, is American culture itself. Our culture is based on the individual’s freedom of choice. And patients may fear that their access to specialists will be restricted. The average Medicare recipient with chronic diseases sees five or six specialists. You might call it the Baskin-Robbins phenomenon. Do you anticipate it will be hard to change this cultural obstacle?

A: I think that’s an issue. Americans are accustomed to running their own shows and not accepting any limitations on freedom of choice. On the other side of that are surveys that show that despite all this freedom there is a fair amount of dissatisfaction and that patients involved in strong, trusting relationships with primary care doctors are amongst the happiest and trust recommendations made by their primary care physicians.

We have conflicting desires on the part of a large segment of the American public. They don’t want to be denied care , but they want the help of someone they trust. Our hope is we can rely on that trust and build upon it by making sure the best information is available from the health care team and that the outcomes will be improved and unnecessary risks will be eliminated without creating the feeling you’re being denied.

The Medical Home can be presented as having more benefit than loss of freedom by sharing information with patient rather than seeing, for example, an endocrinologist, pulmonologist, cardiologist internists in a diabetic with heart failure and COPD.

The Power of a Personal Physician

Q: As you know, I have an ongoing dialogue with Dr. Paul Grundy, IBM’s Director of Health Care Transformation, and he continually impresses upon me that a personal relationship with a primary care doctor has tremendous, underappreciated power for the good. Paul invariably brings up the example of Denmark, where everybody, without exception, knows and trusts their personal primary care doctor – to benefit of Danish society and its health system, which is one of the most efficient and cost effective in the world.

So the medical home concept can be done – and it’s being done, in Denmark, Spain, and New Zealand and in organizations in the U.S. like the Camden Coalition in New Jersey, Community Care in North Carolina, Geisinger in Pennsylvania, a coalition in Detroit, and by Blue Cross Blue Shield of North Dakota. I know doctors in North Carolina who think the Medicaid experiment with a quasi-medical home there has succeeded. Why is that?

Medical Homes Work from Patient and Doctor Perspectives

A. I think the Medicaid folks there, who don’t have some of financial considerations of other patients, perceive that there is someone who cares, who is paying attention, and who is doing the things that they need. They no longer feel the need to head to the emergency department. They have someone to whom they can speak to in the middle of the night or the weekend. There are strong testimonials that this works from patients.

Q: It also works from the doctor’s perspective. One of the concerns of doctors is: Who manages the patient once they leave the office? Doctors are concerned financially and practically and personally: who do I have to hire to coordinate care and who much do I have to pay them?

In the case of North Carolina, doctors are paid are paid a modest fee to see a panel of Medicaid patients, and Social Services division of State Government tracks and supports these patients on the outside. It’s a problem with doctors. They ask: who am I going to hire to coordinate care for those outside problems between visits?

What’s the North Carolina story from the IBM point of view?

A: We point to organizations that have done that successfully, such as Geisinger. We talk in our White Paper about what incentives are necessary for caregivers to participate in this fully expanded process with coordinators and health care teams, and a lot of it is financial incentives. Geisinger, as an example, gives the primary care physicians $1800 a month if they agree to participate in the medical home process to meet reporting and quality standards and an additional amount of money for the infrastructure – to hire coordinators and to train them.


Q: What about the electronic records?

A: That’s a big part of making the Medical Home work within an integrated system, making sure everybody is working with the same information.

Q: At Geisinger, are these primary care doctors salaried employees of Geisinger?

A: in a large fraction of their initial effort, they were. Now they are expanding their effort to include the affiliated but not employed doctors.

Q: To me, it’s a big problem – how to handle independent physicians outside of integrated systems, who constitute 80% to 85% of American physicians. How do you address the problem of the independent physician who wants to become a functioning Medical Home?

A: That’s a big part of our White Paper. There are a variety of ways to do it. It becomes a major obligation of the payers. Money is a common denominator that indicates priorities for the primary care physician. The National Blue Cross Blue Shield Association and its constituents in the various states have different incentives to induce doctors to participate in medical home projects where doctors can show increased patient satisfaction and increased compliance with standards.

What it comes down to is: what kind of financial inducements are necessary to get these independent practitioners to participate? That initial funding is one of the major challenges we are addressing. There are 12 or 15 examples in states around the country where that has been successfully done – Medicaid in North Carolina, the Voice of Detroit Initiative, among them.

The idea is: providing coordinated and comprehensive care and to be measured by quality outcomes is to separate you from the counterproductive volume incentives is a key part of this. We think the financial incentives might include a blended compensation approach: fee-for-service, a patient panel management fee, and bonuses for patient-responsiveness – same day appointments and prompt email and phone answers.

IBM’s Multipronged Approach

Q: I notice in the New York Times that IBM is working with the UnitedHealth Group with IBM employees in Arizona in an experiment to prove the validity of the Medical Home concept and to win over the primary care doctors. That, I assume, is an example of IBM’s multipronged approach to solving problems.

A: I think that’s right. IBM likes to view itself as walking the talk as well as talking the talk. We provide, for example, in the Hudson Valley in New York, additional payments to payers who managed self-funded insurance programs to induce development of the medical home for IBM employees in that area.

Money is the common denominator and demonstrates the commitment. The financial upside is keeping people out of the emergency room, out of the hospital, and away from unnecessary and duplicate care.

Fear of More Bureaucracy

Q: One fear among practitioners are the bureaucratic barriers to qualifying for a medical home. Doctors wonder if the costs - psychological, financial, and time and energy involved - of surmounting those barriers will be offset by financial incentives, dollars per member per month, of whatever the payment mechanism is.

In the minds of practitioners, it’s vague what the incentives are. My advice is to clarify and simplify. Deep in the hippocampus is the fear of being entangled in another bureaucracy.

A: Sounds like good advice. Bureaucracy is the bane of practicing physicians.

Hypersensitive Doctors

Q: Doctors are hypersensitive to any health plan who they perceive to have designs to manipulate or influence them. My own view is that medical homes will work well in integrated systems like Geisinger. It’s the other 85% of physicians in independent practice.

I remember David Brailer, when he was appointed Czar of the national information system, saying the uptake of EMRs by doctors in small practices were the Elephant in the Room, I suspect that’s true here also. Brailer, by the way, resigned in frustration after two years on the job.

A: Do you have any thoughts about how we ought to address small practices?

Lack of Clarity – A Big Issue

Q; I think lack of clarity is a big issue, and that’s what your White Paper hopes to dispel. One clarifying point is decrease in cost, another is demonstrated patient satisfaction, yet another is what exactly is going to be the extra reimbursement.

It is best to keep your message simple and straightforward without preaching too much about meeting standards and improving quality. Your story has to be a continuing one, and you have to keep trumpeting your successes among similar practitioners. The Medical home is not a one-trick pony. It has to be continuing campaign to show positive benefits for patients and doctors alike.

The Physicians’ Foundation

I work closely with the Physicians Foundation, which represents about 500,000 practicing doctors in state and local medical societies. They have been issuing grants to physician organizations to induce them to adopt EMRs. It has been a disappointing effort because doctors in the field find installing EMRs is overwhelming in light of other practice demands.

The response has been negative and muted. For God’s sake, the doctors are saying, we’re already too busy coping with low reimbursements, crowded reception room,s and managed care hassles. This is just another straw that will break the camel’s back.

Doctors are groping for something that will make their lives easier, not harder. Any reassurance you can give them that medical homes will help simplify their lives and pay them more will be a winning argument. Doctors are looking for something that works, something puts them in closer contacts with their patients, something they can achieve under current working conditions.

Support of the Medical Home Concept

A: All major national primary care organizations support the medical home concept. I’m hearing there may be a difference between these organization’s official position and feelings at the grassroots.

Q: I think that’s true. Jeff Goldsmith, of Health Futures, described the chasm between those in the “adminisphere”, those in the executive suites, and doctors in the trenches, as a “chasm.” That may be overstating it, but a gap exists. It’s always tough to close the gap between top-down idealism and bottom-up realism.

Other Fears

A: How could we close the gap?

Q: It would help if you address the major fears – fears of bureaucratic entanglement, fears of inadequate payment, fears of radical change, and fears of when push comes to shove, whether the health plans are really going to ante up for medical homes.

Keep in mind deep-seated hostility exists between doctors and health plans, and the hostility may be bilateral. There’s a continuing war, the Hatfields versus the McCoy’s, going on between doctors and health plans, as evidenced most recently by UnitedHealth, Aetna, and Cigna settling in New York for underfunding of usual and customary out-of-network payments.

A; Do you think there’s any reaction among doctors against the idea of doctors in medical homes collaborating with patients to enact best practices?

Q: I do not think there is universal acceptance of the idea that universal evidence-based protocols, so-called cookbook medicine, will improve care. Nor do I think there is organized resistance. It’s a sensitive issue, and I doubt it will be resolved by “metrics” to assure quality.

A: Is it the fear that data-driven care will improve things, or the bureaucratic consequences of those measurements?

Q;: The latter. It’s the fear of doctors being reduced to mere medical technicians carrying out health plan and government mandates. It’s the fear that metrics are the benefit of the payers, rather than the benefit of doctors who bears the expense of implementing them.

A. It’s the fear of having arbitrary standards imposed upon them that don’t make a lot of sense.

Q; Speaking of sense, let me share with you a conversation I had with a seasoned family physician in North Carolina, who has run the gauntlet of solo practice, group practice, and staring a family practice program at a medical school in North Carolina.

What he said made sense to me. He said a lot of what’s going on is organizational overkill. He said the essence of a medical home is a personal family physician, trained in residency to coordinate and take care of his own panel of patients’ comprehensive needs, and an RN, who works closely with the doctor in the office to track their personal needs inside and outside the office.

It goes back, he said, to the doctor’s and the nurse’s training, and their confidence and skill in taking care and delivering common care, like pelvic exams , minor surgical procedures, injecting joints, or other procedures that can be done safely and proficiently by doctors and their nurses. This may be an ovesimplication but it ‘s worth thinking about.

A: I don’t think anyone would argue that a solo practitioner with attentive personal nurse would need to hire anybody outside the practice to coordinate care. On the other hand, there are environments where three or four physicians might need to hire an outside care coordinator.

Q: My North Carolina friend makes another distinction: he says the role of a solo rural doctor differs from that of an urban internist. As examples, he says the internists rarely does a pelvic and instead delegates that to gynecologist, and the internist rarely performs minor surgical procedures or colonoscopies.

Room for All Kinds of Practices

A: There has to be room for each kind of practices. The fact that the practices are different doesn’t mean the computer access to best practice information would be different. Also the Pitt County, North Carolina, rural doctor might have closer relationship with specialist consultants than the Park Avenue internist. Coordination and cooperation would be valuable for both of them.

Hospital-Based Primary Care Practices

Q: Another thing crops up in my mind. How does the medical home concept fit in with the primary care doctors whom the hospital has hired? Hospital acquisition of primary care doctors has become epidemic again, and hospitals are setting up networks of salaried primary practitioners who are encouraged to refer high-ticket items back to the hospital.

A: Your thoughts have been very helpful. They reflect the challenges of the current health system. One of the fundamental problems we’re addressing are unhappy patients and unhappy primary care doctors and escalating costs that do not stand up well against the rest of the world. Historically, private and federal bureaucracies have been used as punishment rather than as support for doctors. We’ve got to turn that around.

Not Like Europe

Q: I don’t think we’re going to become like Europe where a centralized bureaucracy can command compliance and induce doctors to manage medical homes. Ours is a more complicated situation. The hospital as an employer of squads of primary care doctors is one example. American corporations setting up worksite clinics, which they sometimes call Medical Homes, is another. By 2010 half of the Fortune companies will have worksite clinics, run by salaried primary care doctors using enbedded EMRs with best practice information.

I wish I had some sweeping advice to offer. I very much like the idea of a White Paper that summarizes the opportunities and problems of Medical Homes, which remain very much a work in progress.

A: We look upon the White Paper not as a cheerlead article or a sales brochure but a balanced and through review of all the issues along with ideas how to address the issue. Thank you for your help.

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