Saturday, February 7, 2009

IBM and UnitedHealth Experiment with Medical Homes

Lately I've been dabbling in realism in this blog. Basing our health insurance system on employers is a cockeyed idea that emerged during the World War II wage freeze. But it's the system we have. Happily, employers are getting mad about how much insuring their employees costs and how mediocre the high priced care is, and they're taking some promising steps.

An article in this morning's New York Times reports on a medical home program in Arizona between IBM, which has 11,000 employees there, and UnitedHealth, its insurer. What's important is not the idea, which is mainstream common sense, but the fact that two huge corporations are running with it.

"What we buy is garbage." That's how Dr. Paul Grundy, IBM's director of health care transformation, describes the care health insurance typically provides. IBM catalyzed formation of the Patient Centered Primary Care Collaborative, for which Grundy is chair. The organization advocates for a coordinated, primary care-centered health system based on these sensible principles:
Personal physician - each patient has an ongoing relationship with a personal physician trained to provide first contact, continuous and comprehensive care.

Physician directed medical practice – the personal physician leads a team of individuals at the practice level who collectively take responsibility for the ongoing care of patients.

Whole person orientation – the personal physician is responsible for providing for all the patient’s health care needs or taking responsibility for appropriately arranging care with other qualified professionals. This includes care for all stages of life; acute care; chronic care; preventive services; and end of life care.

Care is coordinated and/or integrated across all elements of the complex health care system (e.g., subspecialty care, hospitals, home health agencies, nursing homes) and the patient’s community (e.g., family, public and private community-based services). Care is facilitated by registries, information technology, health information exchange and other means to assure that patients get the indicated care when and where they need and want it in a culturally and linguistically appropriate manner.

Quality and safety are hallmarks of the medical home:

* Practices advocate for their patients to support the attainment of optimal, patient-centered outcomes that are defined by a care planning process driven by a compassionate, robust partnership between physicians, patients, and the patient’s family.
* Evidence-based medicine and clinical decision-support tools guide decision making
* Physicians in the practice accept accountability for continuous quality improvement through voluntary engagement in performance measurement and improvement.
* Patients actively participate in decision-making and feedback is sought to ensure patients’ expectations are being met
* Information technology is utilized appropriately to support optimal patient care, performance measurement, patient education, and enhanced communication
* Practices go through a voluntary recognition process by an appropriate non-governmental entity to demonstrate that they have the capabilities to provide patient centered services consistent with the medical home model.
* Patients and families participate in quality improvement activities at the practice level.

Enhanced access to care is available through systems such as open scheduling, expanded hours and new options for communication between patients, their personal physician, and practice staff.
Of the Arizona program Grundy says “We’re not doing this because we expect to see huge savings. The medical home is more about whether patients have access to care at the right time and whether that care is appropriate. I think it’s the right thing to do.”

The medical home concept isn't new. The American Academy of Pediatrics introduced it in 1967. What's new is the degree to which businesses are endorsing it. Having a good idea is a starting point. But when IBM talks, people listen!

[For previous postings on how employers can contribute to a more rational and ethical health care system, see here, here and here.]


eric said...

Sounds like an HMO to me. Which is fine. So long as everybody involved knows that it can only work by limiting the patient's choices of providers and institutions. It's counter-intuitive: less choice=better care.

Jim Sabin said...

Hi Eric -

I agree. The medical home concept is very congruent with the ideals of the not-for-profit HMOs: Kaiser Permanente; Group Health Cooperative; Harvard Community Health Plan; and others. The idea of limited choice is part of the insurance system - creating a network that in addition to being well-integrated is cost-effective. A medical home in itself doesn't require that kind of restriction.

As always, thanks for your thoughtful comment!