Primary-care practices across Maine take a new approach to help patients and reduce costs

As an internist, Dr. Carl DeMars specializes in solving puzzling diagnostic problems. For the last three years, as the medical director of Mid Coast Health Services' Accountable Care Organization, he's been practicing that skill in the arena of health care policy as an advocate for a new approach to primary care known as the “patient-centered medical home.”

“I see the patient-centered model as the very foundation of our health-care system,” he says. “Too often we've relied on waiting for sick patients to show up at the door and sending them out with their prescriptions. The patient-centered medical home is all about treating patients proactively. It's about making decisions together with our patients, talking with them about the positives and negatives and the costs of the different treatment options.”

It's time to fix the system from the ground up, he says, pointing to the $11 million investment Mid Coast Health is making to create primary-care clinics in Topsham and Bath that were designed from top-to-bottom to facilitate a team approach to primary care. Together with a clinic in downtown Brunswick, the three medical homes will be supported by coordinated teams of physicians, nurse care managers and behavioral health specialists — all having the mission of helping people to stay healthy, rather than simply treating them when they're sick.

DeMars and his Mid Coast colleagues are not alone in their embrace of the new PCMH direction.

Of the roughly 500 primary care practices in the state, upwards of 175 have begun implementing the new PCMH approach, according to figures provided by Maine Quality Counts, an independent collaborative aiming to improve health care. They extend into every corner of Maine: 75 are enrolled in the pilot program launched in 2010 by Maine Quality Counts, the Dirigo Health Agency's Maine Quality Forum and the Maine Health Management Coalition; another 100 or more were added in the Health Homes initiative overseen by MaineCare and the Maine Department of Health and Human Services.

Because almost 40% of emergency room visits and between 10% and 17% of inpatient hospitalization costs are estimated to be preventable, according to an April 10 commentary in the Journal of the American Medical Association, primary care has emerged at the forefront of local, state and national health care initiatives to reduce costs.

DeMars says patient-centered medical homes offer the right prescription for achieving the “triple aims” of improving people's health, improving the quality and experience of their care and reducing per-capita health-care costs for the 30 communities served by Mid Coast Health Services.

But he also acknowledges that revenues at the 92-bed Mid Coast Hospital in Brunswick could take a hit if the three medical homes achieve those goals and help reduce unnecessary ER visits, hospital admissions and readmissions.

“That's the meat of the matter,” he says, not only for hospitals but also for the primary-care practices that traditionally have been paid on a fee-for-service basis. “With our current health care system, the better job we do, the less money we get. The challenge we face is: How do we flip this system around so we reward quality and improved outcomes instead?”

Statewide pilot program

Dr. Lisa Letourneau, Maine Quality Counts' executive director, says the emerging patient-centered medical home trend is driven by primary-care providers “finally coming together saying, 'What we do is important, we could be doing it better and we should be getting paid appropriately.'” Frustrated by what she characterizes as a “wacky payment model” based primarily on volume rather than quality of care, Letourneau says the 75 primary-care practices involved in the five-year pilot program have signed on to achieving 10 core expectations, including:

• Practicing a team-based approach to care

• Including patients and families in the implementation of the patient-centered model

• Improved management of patients with severe chronic health problems

• Reducing unnecessary health-care spending

• Integrating health information technology to improve communication with patients.

At the same time, she says, payers for health care — both public and private, as well as patients who increasingly are hit with higher deductible and co-pay costs — are all seeking to curb their rising costs. Out of that convergence of stakeholders — patients, providers and payers — came the 2010 pilot program that initially was to last three years. In January 2012, she says, Maine was one of just eight states selected to participate in the three-year Multi-Payer Advanced Primary Care Practice demonstration project testing the effectiveness of the new approach. Funded by the federal Centers for Medicare and Medicaid Services, it provided enough additional money to keep the pilot program going through the end of 2014.

Letourneau says the 75 primary care practices in the PCMH pilot are providing care to 360,000 patients — or almost 25% of the state's 1.3 million people. The additional 100 Health Home practices joining MaineCare's pilot last year will be open also to qualified pediatric practices and will be focusing on patients with asthma, diabetes, heart disease, hypertension, obesity, chronic obstructive pulmonary disease and other chronic illnesses.

“I think it's impressive that we've been able to get as much traction as we have in this state,” she says. “We've got 175 practices doing it in a climate where the payment incentives are very mixed. We picked people who were committed and willing to make these changes with everyone else watching them. That's the kind of leadership we need. The challenges are real. It's not easy to make any big change.”

A work in progress

Letourneau says statistics for the latest progress report haven't been compiled yet. But at the half-way point, she says all of the participating practices had achieved national medical home recognition from the National Committee for Quality Assurance based on a “must pass” checklist of core expectations practices need to meet in order to be certified.

Accountability is built into the checklist, she says, which includes as goals: Patients having same-day access to their provider; proactively identifying patients who are “at risk for adverse outcomes” and creating a care plan that will help them reduce those risks; identifying one to three initiatives to reduce avoidable hospitalizations, emergency room visits and expensive procedures that aren't “evidence-based.”

Anecdotally, she says, some practices in Maine have reported success in reducing emergency room visits by up to 50%. Under the federal CMS demonstration project, she adds, pilot participants are expected to achieve 6% to 7% decreases in avoidable inpatient admissions and 5% decreases in avoidable ER visits, specialty consultations and unnecessary use of imaging and other expensive procedures.

Nationally, she says, the early reports show mixed results. An article in the Journal of the American Medical Association in late February, based on a three-year survey of 32 pilot practices in Pennsylvania, concluded that despite achieving NCQA certification as medical homes, the surveyed practices showed “limited improvements in quality” and did not experience “reductions in utilization of hospital, emergency department, or ambulatory care services or total costs over three years. These findings suggest that medical home interventions may need further refinement.”

A much broader national study published in January by the Patient-Centered Primary Care Collaborative shows mixed results. A few examples:

• Colorado: 15% fewer ER visits (compared to 4% fewer in control group), 18% fewer inpatient admission (vs. 18% increase in control group).

• New York: 11% fewer ER visits for adults, 17% lower for children; lower rates of inappropriate antibiotic use.

• Connecticut: 22.8% fewer monthly ER visits, 20.7% fewer specialty care visits; 75% increase in primary care visits; modest improvements in adherence to prescribed medications for heart disease, blood pressure, cholesterol and diabetes.

• New Jersey: Pilot in Monmouth County shows 33% increase in colorectal screenings (vs. 10% increase in non-PCMHs) and 23% increase in breast cancer screenings (vs. 3% increase in non-PCMHs).

“There's a lot of learning going on,” Letourneau says. “We're all working hard on the basic question of 'What do you need to do to ensure accountability?'”

Reports from the field

Paula Eaton, practice administrator for the Martin's Point clinic in Bangor, says being selected as a pilot site has given her opportunities to learn best practices from peers during monthly check-in meetings. Taking it one step further, she just created a patient advisory committee that will meet monthly to offer suggestions on improving “the patient experience” at her clinic, which sees 3,400 patients a year.

Along with eight other Martin's Point clinics in Maine and one in New Hampshire, Eaton says, her clinic has integrated a behavioral health component into its services to help patients with depression, anxiety, substance abuse and addiction issues. “Many patients don't understand the impact mental health has on chronic illness,” she says.

Among the agenda items Eaton plans to present to her newly empaneled patient committee is the “Choosing Wisely” initiative of the ABIM Foundation — which she sees a perfect complement to the PCMH pilot program because it encourages patients and physicians to talk about tests and procedures that might be recommended as part of their care.

“Choosing Wisely does a great job of making the questions understandable,” she says. “That's another awareness the pilot has brought forward: The cost of care and the need to educate patients about their care … We've seen, since January, when a lot of people began to see higher deductibles, that people are now asking, 'How much is this going to cost me?'”

For Laurie Kane-Lewis, CEO of DFD Russell Medical Center, a federally qualified community health center, the additional per-member per-month fees from payers that include commercial insurers such as Anthem, Aetna and Harvard Pilgrim enabled her to hire case managers for her clinics in Leeds, Turner and Monmouth. That additional staffing, she says, has been key to being able to focus more closely on the health care needs of chronically ill patients.

“That improves outcomes and reduces costs,” she says.

With the pilot program's funding ending at the end of this year, Kane-Lewis says she's pleased that at least one insurer, the nonprofit Maine Community Health Options, has already indicated it will continue paying a per-member, per-month fee to support the PCMH value-based approach to primary care at her medical centers. She's hoping the other payers will do likewise, largely because the new approach already is proving effective in improving health and lowering costs.

“That's the elephant in the room,” Martin Point's Eaton agrees. “A quality-based system can work, but with a fee-for-service payment structure, you don't get paid for those follow-up phone calls. Those all take time, and that takes money. The fee-for-service model has really outlived its usefulness. We need to restructure the reimbursement so that it's based on quality.”

Dr. Barbara Crowley, executive vice president at MaineGeneral Health and Maine General Medical Center, says there's no question that hospitals large and small will be challenged if the PCMH model achieves its goals of reducing hospital admissions and readmissions, particularly unnecessary emergency room visits, thereby reducing their revenue streams. But, she says, MaineGeneral's new $312 million, 192-bed hospital in Augusta embraces that challenge and was designed with a greater emphasis on wellness that's reflected in a wing devoted to an array of outpatient services.

“We feel quite strongly about that,” she says. “We built fewer beds than we previously were licensed for. Our intention is to do everything we can to keep people out of those beds.”

Crowley also serves as president of Kennebec Region Health Alliance, a coalition of 28 primary-care practices partnering with MaineGeneral in a “physician-hospital organization” that contracts with insurance providers and other payers. Of those, she says, 10 are participating in the PCMH pilot program and 20 are recognized by the NCQA as a patient-centered medical home.

Both Crowley and DeMars say commercial insurers and the state and federal payers are increasingly receptive to payment models that will be based on quality measurements. “If you are seen as a high-value health care system, more patients will come under your tent,” DeMars says, noting that pharmacies and insurance companies are also likely to offer lower rates to the patients covered by those providers.

And if it means fewer ER visits, hospital admissions and readmissions, Lois Skillings, president and CEO of Mid Coast Health Services, is OK with that.

“Health care is changing and we're choosing to be part of the change that's going to happen,” she says. “Yes, we have to run it like a business, but our mission is not a business. It's to improve the health of the community. Hospitals need to see themselves as only one component of health care. In today's environment, my role is to be a leader of the entire health-care system, not just of the hospital.”

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