Yesterday Jim attended the Adirondack Medical Home summit meeting in Lake Placid.  Since health care is so critical to the future prosperity of the region, this effort deserves a closer look.  Revolutionizing primary care can lead to much better care in our region.

The Adirondack Medical Home project is one of many efforts around the country to restructure the management and delivery of health care with the aim of strengthening the Primary Care Provider (PCP) role.  This regional effort, which is managed by the Adirondack Health Institute (see recent post) involves CVPH, Adirondack Health (formerly AMC) and Hudson Headwaters Health Network.  It provides incentives (i.e., more money) to primary care providers to take on the role of coordinating care for their patients.  By involving multiple provider networks and multiple insurance companies, it is one of the most ambitious in the nation.

At the conference, excellent presentations explained the data analysis that shows why this shift to putting the PCP in charge can achieve a threefold win:  better health outcomes, lower costs and a better experience for the patient.  The key data show that it is patients with more than one serious chronic condition or with a serious condition combined with a mental health or substance abuse problem who incur costs way out of line with other patients and for whom the health care system often becomes confusing and hard to navigate at best.  The problem is lack of coordination of care across multiple specialists, between physical and mental health services, and with social services.

The “Medical Home” approach puts the PCP in charge on the theory that your PCP is best able to make the correct decisions about your overall care and to see, for example, when drugs for one condition are interacting badly with those being taken for a different condition.  The PCP can also short circuit unnecessary and redundant testing that an individual specialist wouldn’t see or care about.  The goal is to optimize the entire process of care delivery for a patient not just a piece of it.

The other thing that the PCP can do is to work hard on keeping the patient engaged in their own care.  All kinds of studies show that costs go way up when patients get confused or indifferent about what they are supposed to do for their own care (e.g., fulfill prescriptions, go to rehab, etc.).  The idea of health coaches was put forth, who represent a new kind of role in the health care system, but one that can have a huge impact on outcomes and costs.

Using insurance claim data, practices can identify their patients with the greatest risk of problems in coordination and reach out to them proactively with the goal of preventing unnecessary visits to the emergency department or inpatient hospitalizations, which are the primary drivers of the high cost of health care in the US.

The next step in the evolution of this restructuring is to bring mental health, substance abuse and social programs into the coordination role at the Primary Care Provider, advancing us from a Medical Home for each patient to a Health Home that worries about a person’s complete health needs.  Medicaid is moving first to this model in New York but the Adirondack Health Institute is also moving in this direction.

The conference was very encouraging.  We are at the forefront of improving the healthcare system.  We are already seeing a drop in emergency department visits.  Others talked about the beneficial effect this can have on our ability to recruit primary care providers to the region.  One doctor highlighted studies that showed that medical students shy away from primary care, especially in a rural setting, because it appears to be too stressful a lifestyle.  The brain surgeons have more control over their schedule and have plenty of time for golf.  But if we are transforming primary care here and modernizing it, then it can be more rational and less stressful, especially if the compensation is there to support the additional staff needed in care management roles.

On a national level, this shift to the PCP requires that a lot more medical students decide to go into primary care (the most recent statistic cited was that only 2.5% of medical students go into primary care).  The most innovative idea put forth was being tried by a medical school in Texas:  students going into family practice or other primary care roles can graduate a year earlier than specialists.  This would be huge.

Others pointed out that almost all increases over the past 5 years in reimbursement rates have gone to primary care duties not to specialist procedures and that will continue, somewhat closing the disparity between primary care and specialists, who a few years ago earned as much four times that of a family practice doctor.

The big takeaway from the conference, however, was that in the future we will need fewer hospitals and more full service clinics or community health centers.  Many of the small hospitals in the north country will have to close or mutate into something focused more on outpatient services and primary care.  Hudson Headwaters is leading the way, building new clinics in Champlain and greatly expanding the one in Warrensburg.  The other takeaway was that we need to start training new kinds of community health workers to perform roles like health coach, care management and patient outreach.  As our population ages, there will be more service jobs in the local economy devoted to these and other services for the aging.  But we need to develop the training and certification programs for these new roles.