How to Get Off the Hamster Wheel and Find Joy in Medical Practice


The key to making the "medical home" the practice paradigm for primary care is getting insurers to make the early-stage investment-usually in the form of an additional payment per patient per month-- that will pay off in better health outcomes in a few years, says Gregory Burke, of Manhattan's United Hospital Fund. That's happening in New York State, and physicians who are in such practices are much happier, he says.

Physicians and patients who have switched to the “medical home” model of care are often happy with the change.

It improves continuity of care, reduces emergency and episodic care, and emphasizes prevention and screenings, says Gregory Burke, director of innovation at the United Hospital Fund (UHF) in Manhattan.. That is particularly true for patients with chronic illness.

If only every insurance company would agree, Burke adds.

The non-profit UHF is a health policy research and philanthropic organization. Burke is author of a recent UHF report, Recent Trends and Future Directions for the Medical Home Model in New York.

In a recent visit to MD Magazine’s studio, Burke talked about his organization’s efforts to develop these new model programs in the state of New York. The state leads the nation in the number of physicians now practicing in a medical-home model, with 7,600 (14%) of those 53,000 US doctors located in New York. New York State is in the process of designing a new medical home model—Advanced Primary Care—that builds on the PCMH model, but relies less on external certification of the structures and processes of care, and more on the ability of a practice to achieve, maintain, and be able to demonstrate improved outcomes— high levels of performance on measures of quality associated with better health outcomes and lower utilization and cost.

It’s a tall order.

A former hospital administrator, Burke says he is a “delivery system guy” who specializes in making changes happen.

Neither patients nor primary care physicians are happy with the current “maze of the medical care that is now the delivery system,” Burke says.

The “medical home” model breaks down the siloes.

One obstacle is getting the insurers to agree to pay more for medical-home care. It can be a tough sell since many companies participating, for instance, in the Medicare Advantage managed care plans are already losing money.

“They have red bottom lines and you come along asking them to pay more money,” Burke said.

But it doesn’t take long for those companies that do so to see this care is more efficient and keeps people out of the emergency room.

One key is making sure physicians set up a system in which they cover for each other, so patients do not have to go to the ER when a problem arises off-hours.

The medical home model can be challenging for small or solo practices. “They don’t have the scale of the ability to absorb the losses in income” But the fact that the physicians in such practices know their patients better “gives them a leg up.”

The other challenge is the cost of good electronic medical records systems, and the additional staff it takes to follow up with patients, beyond the visit-based payment system.

The best argument for convincing physicians and payers that the investment is worth it is “this will save you money” usually within a year or two you can really come up with measurable changes.”

That is particularly true in caring for high-cost patients, like those with hypertension or diabetes, or some of the other chronic illnesses.

Their visits to the ED should drop.

“New York is a bit of a pioneer on this stuff,” including a pilot project in the Adirondacks region of New York State, Burke said.

Primary care providers in five counties got payers to agree to pay them seven dollars per member per month so they could form a medical home entity that would qualify as a NCQA Level 3 medical home, the highest rank they offer.

There was a similar initiative in the Hudson Valley region. Both were funded by the Centers for Medicare and Medicaid Services, but began in New York.

In the Adirondacks project, physicians were getting another $3.50 per member per month.

The first issue that they dealt with was cross-coverage so patients would be able to see or at least talk to a physician outside of normal office hours.

“You cannot just have an answering machine that says ‘if you are sick, call 911’,” the doctors agreed, Burke said.

As for concerns that patients seen by a covering doctor might migrate to that physician, it just didn’t happen. “Nobody was stealing any patients,” Burke said.

One obstacle is that in New York most physicians participate in many insurance plans. “You may have five, six, seven different payers covering the patients that you’re serving,” Burke noted.

All have to agree to participate or the new model won’t function.

“The prediction for New York and the rest of the country turns on the simple equation: delivery system innovation requires payment system innovation,” he said.

“At the moment, it’s a cacophony,” he added. But as cutting health care costs and improving outcomes remains a US goal, creating medical homes beats bundling payments, or other forms of “wishful thinking.”

“It’s the best horse on the track,” Burke said.

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