The Medical Home as a Primary Care Solution to Health Reform

April 13, 2011 - In my book Obama, Doctors, and Health Reform (2009, available on Amazon), I have the following chapter, “IBM Puts in Its $2 billion and 2 Cents Worth,”featuring a speech by Paul Grundy, MD, director of health care transformation at IBM.

Dr. Grundy is a driving force behind the medical home concept, an innovation prominently mentioned in the new health reform law.

According to the Engelberg Center for Health Reform at the Brookings Center, the medical home has general strengths and weaknesses:

It supports new efforts by primary care physicians to coordinate care, but does not provide accountability for total per capita costs. It does not necessarily give incentives to hospitals and specialists to participate, encourage global accountability, decrease volume, or put primary care doctors at risk. On the other hand, it requires patient assignment and a per member, per month payment structure.

Chapter Seven , IBM Puts in Its $2 Billion and 2 Cents Worth

Insurers’ corporate customers have been increasingly critical of the value of their health coverage. I.B.M., for example, says the industry is not helping to provide care that’s more cost-effective in helping their workers live longer and more productive lives. The insurers “don’t have a clue about providing what we really want to buy,” said Dr. Paul Grundy, the executive at I.B.M, who oversees its health care efforts.”

Reed Abelson, “Health Insurers, Poised for Round 2,“New York Times, March 1, 2009

If I’m elected President, I will support patient-centered primary care.

Barack Obama, during his successful Presidential campaign, 2008

What follows is the text of a speech delivered by Dr. Paul Grundy, Director of Healthcare Transformation at I.B.M. He’s giving this speech, or variations of it, as he crusades around the country, speaking to legislators, governors, policy makers, physicians and anyone who will listen about the importance of personal primary care physicians for patients, as embodied in the concept of the medical home.

I.B.M. spends $2 billion a year for health care for its employees, and Grundy feels too much of this money flows to specialists for procedures, rather than to primary care doctors, for prevention.

Grundy envisions “transformation” of American medicine to a patient-centered, primary care-system powered by real-time electronic communications between all major health care parties.

Grundy does not think nurse practitioners or nurse “doctors,” skilled, though they may be, will replace generalist physicians. Nurses are trained to be supportive and nurturing, he notes, but have not yet proved to function well or for long in independent accountable practices.

Furthermore, Grundy insists American already has, in effect, a single-payer system. It’s comprised of Medicare, Medicaid, and a private coding update system that favors specialists over primary care physicians. The reimbursement and support system for primary care physicians has to improve to encourage more medical students to enter primary care.
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Last year, Dad died in Houston, Texas, at age 87 of congestive failure with complications. He had multiple specialists but no personal primary care physicians. Dad had no personal doctor to whom I could turn to help me and my family understands the totality of what was going on.

As Director of Health care Transformation at I.B.M., Dad’s death brought home to me why I’m fighting so hard to change the care we buy for our employees and dependents. That change is the patient-centered medical home. The medical home focuses on providing better and more comprehensive primary care. For our employees, this case will serve as a “fence” to reduce the “ambulance fleet” of expensive specialists at the bottom of the expense cliff. Present care costs are unsustainable at I.B.M. and the U.S. as a whole.

In a February 6 New York Times piece “UnitedHealth and I.B.M. Test Health Care Plan “, I called the present care I.B.M, buys as “garbage.” Perhaps “garbage” overstated the case. But the lack of coordination in my father’s case frustrated me.

We have to make health care, institutions, and industries smarter. Not just at moments of crisis like we see today, but integrated into our day-to-day reality. Our current health care processes are simply not smart enough to be sustainable.

Think about how many of the medications we prescribe that go untaken or interact badly with other medications another doctor gives you. We lose tens of thousands of lives every year because we don’t have the data and systems in place to address the simple issue of medication.

Here’s where technology can help. A computer can provide connection and memory for a doctor’s brain. Just as an x-ray allows the doctor’s vision to expand, it’s health IT that allows his mind to expand and be connected in real time to thousands of other minds and to real data that makes a difference.

In truth, the health care system isn’t a “system” at all. It’s antiquated. It doesn’t link diagnosis, drug discovery, health care deliverers, insurers, employers, and employers. Meanwhile, personal expenditures on health now push more than 100 million people worldwide below the poverty line each year.

Smart health care can lower therapy costs as much as 90 percent. That’s what ActiveCare Network, based in Columbia, South Carolina, is doing for more than two million patients in 38 states. ActiveCare monitors delivery of people’s injections and vaccines so they can lead active and independent lives.

The single most important part of healing is the patient-personal physician RELATIONSHIP. It’s health care’s backbone. Smart health care supports that relationship by improving communication, allowing expanded communication with a patient, and empowering the doctor.

Personal doctors tend not to forget to ask an important question, be it about the patient’s personal life or a key fact to the healing process. Smart health care can send little reminders of care compassion and express a doctor’s investment in a person who needs a healer and healing.

A smart health care system can help with compassion by reminding the patient of important things that would otherwise be missed in a busy doctor's life like e-reminders of a visit, or that mammogram that was forgotten to be completed.

Smart health care makes sure that the right drug is used on the right patient at the right time, taking into account the person’s genetic makeup other medications they’re taking. It ensures authenticity of pharmaceuticals and security of patient information. It changes everything from how health care organizations do business to how they enable their employees to collaborate and innovate.

In the U.S., we at I.B.M. estimate that smart health care will generate lots of new jobs in companies small and large, but most will be small. In a recent conversation with the Obama administration, I.B.M.’s CEO Sam Palmisano estimated that widespread adoption of personal health records will create 212,000 jobs.

I’m not just referring to large enterprises, but also to smaller and mid-sized companies— engines of economic growth. When we think about systems like health care supply chains, health care delivery, care management, prevention, we’re really talking how hundreds, even thousands of companies, most of them are small, interact.

In the Mid-Hudson valley here in New York, we’re already on the path to deliver integrated health IT to all doctors and hospitals. This has created small companies like Med Allies in Fishkill, whose 40 employees work with doctors’ offices to get them up and running with health IT and keep them connected in a powerful and useful way for the patient. In North Dakota, there’s a small company called MDdatacore that provides the register for all the doctors in North Dakota. It now employs 42 folks.

Smart health care is giving rise to a new model for primary care, the “medical home.” About three years ago, the people at I.B.M. started talking about all the things that large employers in the U.S. have done to reduce costs and improve quality. We realized we were failing to address a fundamental issue: primary care and the doctor patient relationship.

Shortly after that, I helped found the Patient-Centered Primary Care Collaborative (link PCPCC), a coalition of large employers, consumer organizations and medical providers.

We developed a health care model based on the premise that’s more holistic. Primary care saves money by cutting the incidence of major health problems like heart disease or diabetes later in life. It’s a back-to-the-future approach to the family doctor, enabled by IT.

In the medical home model, a primary care physician acts as a health care coach – leading a team that manages a patient’s wellness, preventive and chronic care needs. The doctor spends more time with the patient in person, is available for consultations via email or phone, and has expanded hours and coordinates across an entire care team – nurses, specialists, pharmacists and hospitals.

A diabetic could give daily blood test readings by phone, email or remote monitoring device and get instructions the moment she needs them, rather than wait for an appointment. Her care team would have a holistic health plan that focuses on diet and exercise as well as monitoring glucose levels.

This is already happening outside the U.S. In the U.K., they have adopted a similar “family doctor” model that makes health care more accessible and effective – and makes patients happier.

Electronic health records – central in the U.S. health care stimulus bill – are pivotal to making medical homes work. Electronic health records are the single source of information that can be shared across a network of providers and specialists. There are other IT tools that can help patients and doctors alike – online portals to make appointments or look up lab results, or e-prescribing.

Health analytics can look across a patient’s history and pick up trends that provide insight into the treatment of a disease. The list goes on. But it’s important and can’t be stressed enough. That technology supports the care and compassion in the doctor patient relationship but will not replace that or even get in the way of it.

Over the next couple of years, there will be winners, and there will be losers. And though it may not be easy to see now, I believe we will see new leaders emerge who win not by surviving the storm, but by changing the game.

The importance of this moment, I believe, is that the key precondition for real change now exists: People want it.
Summary
Trust your family doctor, and think about the concept of the medical home., especially if you work for a corporation paying your health bills. Employers pay 68% of the nation’s total health care bills, and their ideas are to be heeded. When you’re I.B.M.’s Director of Health Care Transformation, Doctor Paul Grundy, you think of your employees’ health from Monday to Sunday. For them you seek better prevention and higher productivity through primary care doctors with overall patient accountability, So you crusade for Medical homes every moment of every day.