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Hope lies in health care experiments



Last modified: Sunday, January 23, 2011
While Republicans in Congress fulminate about repealing what they call the "job-killing health reform act," serious people, unhampered by political ideology, are carrying out experiments that could change the practice of medicine, improve patient health and reduce costs. Some of those experiments are being conducted in New Hampshire, in clinics that have adopted the "medical home" model of care, in which a coordinated team of providers serve all of a patient's needs.

Truly controlling health care costs will require switching from fee-for-service medicine to a system that pays providers a lump sum for keeping people healthy. But that change could be a long time coming. Meanwhile, experiments suggest the medical home model is working now to reduce costs and improve patient outcomes.

Concord Hospital's Family Health Center began the transition five years ago. The medical clinic, which serves a primarily low-income population, also operates a dental clinic and employs social workers, people trained to deal with mental health issues and case managers who coordinate care for patients across the health care system. Records are kept electronically, so any provider can instantly access them. Members of the clinic team talk to each other about patients, and each encourages patients to make the lifestyle changes that will keep them healthy.

The clinic has stopped scheduling appointments months into the future whenever possible. Instead, it tries to provide whatever care the patient needs that day. The ability to be seen promptly, whether for a sore throat or diabetes, reduced the number of times the clinic's patients went to the emergency room, the costliest place to deliver care, by 40 percent.

Better care of chronically ill patients can yield considerable savings. In the current issue of The New Yorker, Dr. Atul Gawande describes research that found that 900 people living on just two blocks in Camden, N.J., ran up $200 million in hospital bills between 2001 and 2008. One patient had 324 emergency room visits and hospital admissions in just five years. Throughout the city, 1 percent of the patients accounted for 30 percent of hospital costs.

The doctor who conducted that research, Jeffrey Brenner and his team targeted 36 of the patients whose care was the costliest. By taking a medical home approach that included home visits by nurses and health coaches, follow-up calls and social work, the team cut the $1.2 million per month that those patients cost hospitals, to about $500,000. Big savings are easy to get when the costliest patients are targeted. What remains to be seen is how much the medical home approach can save with patients who get an average amount of health care.

Insurers, and Medicare pilot programs made possible by the health care reform act, are paying providers extra to care for patients in a medical home setting. Typically, if the cost of care doesn't go down, providers have to pay the extra money back. If the savings are large, the insurer takes a portion and the providers keep the rest. Such systems save, for example, by eliminating the incentive to order needless tests, while making it unwise not to order the tests necessary to keep patients from getting worse.

Experiments are also under way in New Hampshire to test the "accountable care" model of delivering medical services. Under it, one group of providers becomes responsible for coordinating an individual's total health care. If they exceed the norm in providing quality care and lowering costs, they get a bonus. If they don't, they earn less.

The old ways of providing medical care have become unaffordable. Fortunately, New Hampshire is one of the places where new methods are being tried.