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We are struggling at work with trying to retrofit a new medical school curriculum using a traditional medical school faculty. My non-medical reading is occasionally about the cathedrals of Europe; my favorite fictional account of that time is”The Pillars of the Earth.” While looking for resources to help in our struggle with the retrofitting problem I ran across my friend, Paul Grundy’s, explanation of how care delivery will change, found here. Informing my colleagues that Paul says the Master Builder model of education has been found wanting and showing them the movie may not help with the struggle (change is hard). Picturing the Dean as Tom Builder might help make the meetings go faster for me.

My wife (and editor) is a columnist for a hyper-local start-up trying to compete with our local newspaper. She wrote a column, published today, on the trials of one of our (now deceased) “urban chickens.” The story takes the reader from the designer chicken coop to the vet who specializes in urban chickens, through the diagnostic testing (mostly physical exam), and the outcome (the chicken had to be “euthanized”). We have had several conversations about this event in our household, mostly around how a vet can charge so much money to diagnose a bird that one can get pre-cut up at Food World for 69 cents a pound with a coupon. Mostly, I filed this under people with extra money do odd stuff for their animals and vets are willing to work with us to facilitate this behavior. I couldn’t help but reflect that in the old days, the county agent would have provided the diagnosis (“That’s bad”) and offered a free solution (wringin’ its neck). Or so I learned from watching reruns of Green Acres while I was growing up.

In catching up on a backlog of New England Journal articles, I came across an article that points out the cost-effectiveness of environmental prevention (either through creating opportunities such as walking and bike paths or prohibiting bad behaviors such as driving without seat belts) when compared to individual focused efforts such as screening for colon cancer. I also read the review of the Insitute of Medicine report on childhood obesity in a subsequent issue. Disturbing was the breakdown of attribution of cause by political ideology, with “conservatives” more likely to blame children for their own obesity. Another Bloomberg article points out that physicians are at times willing accomplices in subverting any requirement for personal responsibility. The writer documents physicians self-referring into a surgery center that gives them a tremendous profit in exchange for only referring folks with the “right” insurance and looking the other way as the insurance companies were milked (or bilked, depending on the outcome of the lawsuit) for excess payments.

In short, to improve the health of the country we are going to have to make societal changes that lead to prevention, convince 30% of the population that this is not socialism, and find ways to keep physicians and others from gaming any new system. Paul Grundy, my friend with the Patient Centered Primary Care Collaborative, would see the chicken story as a metaphor for a broken system but would understand the need for a county agent approach. He sent me an advanced copy of  their newest report (to be released September 6) entitled “Benefits of Implementing the PCMH: A review of cost and quality results, 2012.” The Patient Centered Medical Home is a way to organize care delivery that combines the best of high value physician interaction, rewards for population health, and identification and elimination of waste. The new assessment of this method of care delivery is:

The PCMH improves health outcomes, enhances the patient experience of care and reduces expensive, unnecessary hospital and ED care.

It is being implemented across the country with the following consequences:

  • As medical home implementation increases, the Triple Aim outcomes of better health, better care and lower costs are being achieved.
  • Medical home expansion has reached the tipping point with broad private and public sector support.
  • Investment in the medical home offers both short- and long-term savings for patients, employers, health plans and policymakers.

Note that the outcome for human patients (better health) is different than the outcome for chickens (stewpot). I hope for the sake of all of us that we achieve these outcomes (for people). Now if only we can bring a County Agent to Mobile who knows about chickens.

My friend Paul Grundy has begun a blog on the IBM website, found here. In his first installment, he details the events of why, in part,  I am more optimistic about the future of American healthcare for having worked with him. In the first part of his entry, he identifies why IBM has more than an intellectual interest in health care:

With this information, [Watson, the IBM supercomputer] can suggest options targeted to a patient’s circumstances. This is an example of technology that can help physicians and nurses identify the most effective courses of treatment for their patients. And fast: in less than 3 seconds Watson can sift through the equivalent of about 200 million pages, evaluate the information, and provide precise responses. With medical information doubling every 5 years, advanced health analytic systems technologies can help improve patient care through the delivery of up- to-date, evidence-based health care.

The point he makes following this, though, is not that the computer will lead to a reduction in health costs by decreasing the need for human interaction. This data needs to be converted to actionable information. That is where IBM, the company that purchases health care, has taken the lead:

So, how to make sure this actionable information flows and is held accountable at the level of a healing relationship?With this question in mind, in 2006, IBM – as a buyer of care- hosted a meeting for 47 of the Fortune 100 buyers, TRICARE, the federal Office of Personnel Management (OPM), buyers and the whole house of primary care. They agreed to guidelines now known as the Joint Principles of the Patient Centered Medical Home (PCMH).

This is how the Patient Centered Primary Care Collaborative got its start.From this group came many of the elements of care transformation included in the Affordable Care Act.

As you can see, Paul and IBM have influenced healthcare for the better and will continue to do so. If you have an interest in policy, specifically where its going as opposed to where it has been, I would advise you to pay attention to his thoughts.

Blue Cross of Louisiana is following Dr Berwick’s advice to act locally. For years in Louisiana care was delivered by specialists in the usual disjointed, uncoordinated fashion driven by dominant hospitals and medical schools. On December 2 a summit was held at the Pennington Research Center in Baton Rouge to initiate a sea change in the way care is delivered. They announced the rapid deployment of a primary care based patient centered medical home delivery model. In their press release, they cite the following data as contributing to this change:

According to the review, in South Carolina, patients in the patient-centered medical home started by Blue Cross and Blue Shield had medical and pharmacy costs that were 6.5% lower than the control group. Patients in a similar Blue Cross program in North Dakota saw hospital admissions drop by 6% and emergency room visits fall by 24%. During that same period, in the control group, hospital admissions were up by 45% and emergency room visits rose by 3%.

They go on to say

“The healthcare industry is facing unprecedented change. Blue Cross and Blue Shield of Louisiana has answered the call for new and innovative delivery models by embracing the concept of the patient-centered medical home,” said Mike Reitz, Blue Cross President and CEO.

“Accountable, collaborative, coordinated care delivered through the patient-centered medical home will transform healthcare delivery,” said Dr Kenneth Phenow, Blue Cross Chief Medical Officer. “As an industry, we have evolved as far as we can using costly, fragmented, fee-for-service payment. As we transform, pay-for-value models like those embodied by the PCMH approach will help us achieve better health and better care at a better cost.”

Mike Reitz reiterates his support for the concept as well as the importance of primary care on a video captured by Bayou Buzz found here.

This was e-mailed to me by Paul Grundy under the headline “PCMH as seen explained in the deep red states by an enlightened plan.” Anyone from Alabama listening?

I have been a follower of Paul Grundy for a while. I first wrote of him in 2008 (the year that I first met him). In 2009, I posted a link to his slides regarding the US healthcare “system” and also wrote of an effort he made to transform Alabama healthcare delivery. I went to the Alabama Rural Health Conference in Tuscaloosa this week and heard him again today. He is a compelling speaker and plugged into the federal level  transformation.  He believes in the system he is trying to get American’s to purchase. He claims that the Accountable Care Act  ACO section was written to allow the Patient Centered Medical Home to be operationalized. It only requires the capacity to care for 5000 Medicare lives which means that a reasonable small primary care office could qualify. In his talk he points out that Denmark has transitioned from 122 hospitals to 20 hospitals and the bulk of the care is done in the PCMH using enhanced home monitoring and proactive rather than reactive care. His other major point is that the PCPCC is a collaborative arrangement that includes large employers and government payors so there will be no repeal and replace…they like the bill and the rules are going to be written and so ingrained that care delivery will be changed forever no matter how many conservative Republicans think otherwise. He point to the VA and DOD efforts as proof positive. Private groups are consistently demonstrating a reduction in cost of 10% or more. Threatening if you make your money off of third-party administered claims (as does BC/BS of Alabama)… 
 

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