July 8, 2009
Media contact: Paige Rohe, The Carter Center, prohe@emory.edu, 404-420,512
There's No Place like Home, for Your Health: Are Medical Homes the Answer to the Health Care Crisis?
Transcript of media briefing conducted during the Carter Center's
Medical Home Summit
Participants:
Introductions are made among the panel participants with the above information being shared.
BARTLETT: Thank you so much for joining us. What we'd like to do today is tell you a little about a meeting that we've been holding, here, at The Carter Center the last couple of days. The meeting is focused specifically on something called the medical home, the patient-centered medical home. The patient-centered medical home is a concept that has been promoted and is frankly receiving a lot of interest in the discussions about health care reform in this country at this point. It has been promoted by four of the major primary care organizations: The American Academy of Family Practice, the American College of Physicians, the American Academy of Pediatrics and the American Osteopathic Association. And they actually got together a couple of years ago and promulgated a set of guiding principles for what really is a reinvention and a modernization of primary care in this country. And I think that is a very important concept.
Now, why is the Carter Center's Mental Health Program holding this medical home summit? As you know, Mrs. Carter has been a leading advocate for people suffering from mental illness and addiction for many, many years. She's focused a lot on issues of access and improving quality of care, reducing stigma and those have been her particular issues of interest. The bottom line is that a significant amount of mental health and addiction problems are seen only in the primary care setting. For example, about 50 million Americans every year suffer from depression. 50 percent of those never get treated at all, but of the people who get treatment over half get their treatment only in primary care. So, in a way, the primary care setting is kind of the de facto mental health and addiction delivery system in the country.
And the question really is, "Has it been designed to really do well?" The evidence suggests that people who do suffer from mental problems (addiction, depression, anxiety) don't do very well in the primary care setting. And, in fact, the primary care setting is not really designed to do well by them.
Primary care physicians are seeing a lot of patients and don't really have time to sit and talk with people. And primary care doctors are, by the way, also concerned about this. So this concept of the medical home is really an attempt to modernize and transform the primary care delivery system in the country. The reason we're hosting the medical home summit is-as advocates for the mentally ill and people suffering from addiction-we're very concerned that there's a place at the table within the medical home for behavioral health care.
We also saw the opportunity, frankly, to invite our colleagues from health promotion prevention because they also have not traditionally had a place at the table within primary care. And so we've been very, very concerned that they [do] also, since there's been a tremendous amount of emphasis in the discussions about heath reform around the whole concept of health promotion and prevention. And so that's really been the purpose. What I'd like to do at this point is ask each of the panelists to sort of give a brief summary of why they came here and what they're hoping to get out of the meeting. Nico, do you want to start?
PRONK: Sure, sure. From a health promotion and disease prevention perspective, it's actually quite exciting to be at the table and to be part of the discussions and conversations, because as the design of the medical home goes forward, it's important that, by design, health promotion and disease prevention is represented. We know that there are multiple determinants of health; actually the socioeconomic status of people, social circumstance, their access to healthcare, their genetic predisposition - they are all important factors. But the one that actually stands out that explains roughly 40 percent of all of this, of all the health status, is related to behaviors. And so, the idea that the medical home can become an access point for people to actually successfully access resources that may help them change behaviors, reduce risk factors, or even give them access to services that will help those risk factors from even occurring is an important component.
And so, in the context of the medical home and providing those resources when you have a teachable moment, if you will, with the patient that could be just a real powerful way to access these services across the community. So really from a health promotion and disease prevention perspective, being here and being part of the conversation so there is an appropriate role in the patient-centered medical home for health promotion and disease prevention so that health can be generated. In fact, costs of care can be reduced significantly by reducing both the need as well as the demand for medical health care services. [This] is one of the major objectives.
BARTLETT: Wayne, I know that you are a practicing pediatrician, but you also have lead responsibilities for all the initiatives at Intermountain about primary care and behavioral care working together. So, what brings you to the meeting?
CANNON: Well, you know health care reform is about improving quality, improving access and decreasing costs and as a pediatrician I've lived through the era of fragmentation of care. It's difficult to get help for our patients with behavioral health problems. It's difficult to help them. If they find help, it's difficult to get them there. And there are models that would work very well in the medical home for behavioral health. There are existing models in the country-there's more than one. And if they have that information available so that behavioral health services can be part of any medical home, it's critical. It helps patients, helps practices, increases access, reduces costs.
BARTLETT: Linda, you're a social worker by training but I know your organization is very, very involved in this.
ROSENBERG: We're really interested, really in two directions. In one way, we know, or we expect and hope that more people will have coverage, will have medical insurance as a result of the work going on in Congress right now. But those people will need a place to get their care, and we do believe that everyone needs a physician, a primary care doctor that helps them manage any illness they have as well as helps them stay healthy whenever possible. And I think one of the things that Dr. Bartlett said that was very true was that this whole concept of the medical home really modernizes that old-fashioned family doctor concept.
So, we're very interested that any medical home have a team that includes behavioral health care specialists. We know that many people present with serious illnesses, diabetes, cancer, heart disease where they have co-morbid depression, anxiety and issues that need to be addressed and you need a team of people in this health care home or this medical home that can do that. We're also interested in it from a perspective of people with serious mental illness. In 2006, the study that SAMHSA that put out, informed us that people with serious mental illnesses are dying 25 years before their peers and that's been a major focus of the National Council and what can we do about that. And those people often are treated in community mental health organizations, and those organizations have to develop the capacity to do some primary care or more importantly to partner with a primary care practice in their community. And so, we see the medical home as an opportunity to treat the whole person and then of course to move into the area of health promotion and prevention.
BARTLETT: So, what I hear you saying is that in the medical home it's not just the primary care physician working alone. That he or she has access to a whole variety of other specialties? In what other ways does it modernize primary care?
ROSENBERG: I think the other thing, from our perspective, that we're very involved with in terms of health care reform is health information technology. I think when we think of your old-fashioned family doctor they didn't necessarily have electronic health records. But even perhaps more importantly than that, they didn't have systems that were able to notify you, to remind you and prompt you about the kind of things that you needed to do. Whether you're on a diet and needed to be reminded to be measuring your calorie intake, or did you do your exercise that day, or that physician's office needs to be able to track your blood pressure and all your health status information so that they can remind you when you're due to come in again. That kind of tickler system, automated, is really part of the whole push around health information technology. So, for me that's one other way it gets modernized.
BARTLETT: So am I going to get tweets from my primary care physician?
ROSENBERG: I think you might actually. I might tweet you later.
BARTLETT: Wayne, what are some of the differences that you see in the way that primary care has traditionally been practiced? And I know, by the way, that Intermountain is a leading organization nationally, so maybe you can talk a little about how primary care is practiced in the community where most people would get their care, not at a leading organization like Intermountain Health Care?
CANNON: How it is now?
BARTLETT: How it is now and how a medical home would make a difference?
CANNON: Twenty-five years ago, when I started practicing, we spent most of our time treating meningitis, asthma, pneumonia-a lot of time spent in the hospital. These days, there are many differences. I spend my time in the office seeing patients for preventative care and behavioral health. And traditionally, when a clinician will see someone with behavioral health problems, in almost every circumstance research shows that outcomes are better if they have support from someone along this area-therapy, counseling, working with the school. And, in the current model, to try to provide that with a patient is problematic.
There are problems with finding someone who can actually provide the service. There are problems with the family feeling comfortable going somewhere they've never been before with such a sensitive problem. Plus, patients with behavioral health problems sometimes have a little more trouble getting going. There are sometimes problems with payment by whoever is paying the mental health provider. And then, once they do go, it's a black hole. The primary care physician doesn't ever really hear back from whoever saw them unless the family reports directly. So that's kind of the traditional approach to mental health treatment and primary care.
BARTLETT: And this isn't a small problem mind you, I understand. I've heard some people say that 40–50 percent of the patients in primary care have depression, anxiety and addiction, something like that. So this is really a major part of their workload. Now they may have other conditions as well, but…
CANNON: That's definitely true.
BARTLETT: So, hopefully as the patients and the medical home advances those people will again have access to evidence-based approaches to getting their addiction, their depression, their anxiety treated in primary care. And it's clear that not all people who suffer from depression, anxiety and addiction need to go to specialty care. A lot of them can be treated quite appropriately but not necessarily by the primary care physician him or herself. Right, Linda?
ROSENBERG: I think the other thing is that specialty mental health and addition staff also need to change and to close that loop for the primary care provider. I think that's an obligation we have that hopefully, in this new, modernized world, we will understand that we cannot just treat an addiction or mental illness apart from the rest of the person's condition or the rest of their life. So, we have an obligation, if you refer someone to us, to get you that information directly and in a timely fashion.
BARTLETT: I know that so much of the discussion on health reform focuses on cost. Maybe you actually have some data from Intermountain about how these kinds of approaches can help save money?
CANNON: Yeah, I think that in the scientific literature we don't expect to save a lot of money on the medical side by doing this. However, we found that at Intermountain. We've heard at this conference many other places have found significant savings in medical expenses by implementing a medical home for behavioral health problems. Even more than that, there are greater returns for the employer, for the school and for the family, such as quality of life and greater productivity.
BARTLETT: And for the physician himself as well, if I'm not mistaken?
CANNON: And the physicians are much happier, plus it saves money.
BARTLETT: So, is this one of those rare examples where you can do well by doing right?
ROSENBERG: That's right.
CANNON: I think so.
BARTLETT: Nico?
PRONK: Well, I would echo the comments from Wayne. In fact, on the prevention side, health promotion and disease prevention, it's a strong argument for cost savings, not only in the context of medical care, but also in productivity. And that is a strong and emerging literature, but it doesn't even take that long either. These are not outcomes that take 10 years to achieve. In fact, if you just look at the decision to do nothing and keep the status quo, then within 18 months, there is a significant excess cost incurred because you avoided health promotions and disease prevention. And when you put these programs in place, they focus on behavioral and lifestyle solutions, such as: diet, not smoking, being physically active, no risky drinking. The savings can come about in a year or two years, but particularly from an employee perspective where the productivity side shows up as well.
BARTLETT: I do want to follow up on that because all of us stopping smoking, I mean I get that at my local church and things like that. What is it about the medical home that so intrigues you from a health promotion and prevention point of view?
PRONK: Well, I think the key differentiator is the fact that the referral into those lifestyle/behavior change programs comes out of the trusted relationship between the physician and the patient. And it's the effect of the fact that they've had an opportunity to assess that risk in the context of the clinical encounter-that you have a face-to-face, one-on-one conversation and heard advice from your clinician that this is important in the context of your care plan, whatever that may look like, and then you agree to actually take action on that. When the referral then happens, we see very high uptick of these services among patients. So, I think in the context of that scenario you just increased the successful intervention. And therefore, it is so key to actually extend that care team, if you will, outside of the clinic, into community-based resources or other venues like the employer setting.
BARTLETT: So, it's another example of you may have an effective intervention, but if it doesn't get used people… (PRONK interjects)
PRONK: If it doesn't reach people or if it reaches people at inopportune moments versus them being activated and involved in a teachable moment in which they are truly engaged.
BARTLETT: At this point, what we'd like to do is open it up to questions from the media.
(Female voice speaking): My question is, going back to the medical home model, the coordination of care management. Do we understand how that would be facilitated to make sure that the patient's primary care doctor and all of the specialists would be kept in the loop? Would that be with the case managers, or would that be a project for the facility to determine that?
BARTLETT: Wayne, you want to address that?
CANNON: Your question is who does the care management or is it about how does communication occur? (pause) Or both?
(Female voice speaking): Both, really. With the coordination of care, I would assume that there would be a case manager but I wasn't sure if that would be facilitated in a single sort of model with the insurance company or the provider having to coordinate with the case manager or how that would work so that we know it has a uniform success rate?
CANNON: Part of setting that up is answering that question. It will be different in different communities; so it will be different in a small, rural community versus a large, metropolitan area. Typically, on average, behavioral health and the primary care physician would be located in the same office and be using the same materials to communicate, to make records. So, there's a common medical record and an established way of communication, whether it's by messaging within the medical record or by e-mail. And the care manager is another part of the team. There's a million different ways to do care management. Ideally, they would also communicate through that same method, typically face-to-face and electronic.
BARTLETT: I think I heard you say yesterday, "You know there's no single design for the medical home. It has to work on a local level and local community down to the individual doctor's office." I think I heard you say yesterday, you have like 50 different clinics within Intermountain across the western states, mostly in Utah, and not all of them have the same approach, right?
CANNON: Well, we have small, rural clinics and large, metropolitan clinics and the design has to be modified depending on your resources.
ROSENBERG: I would just add, because in your question I think you're also asking about whether there is coordination at the insurance level or is it at the site of service level? I think that's what I heard, and I think certainly one of the guiding principles is that the coordination and relationships are as close to the site of service as possible. This isn't something that an anonymous person is managing your care over the phone maybe insuring thousands and thousands of lives. But this is where you have a physician you go to for care and that physician has someone in their office or they coordinate with someone to make sure that the information from any specialists they refer you to and that they also may refer you to an exercise program, but it is all emanating under that clinician's auspice.
BARTLETT: Yes, and I agree it should be as local and low-level as possible. Although they did have some interesting experiments going on. Aetna, for example, is running a very successful program where their case managers are working in partnerships with the primary care physicians who don't necessarily have access to extra resources. These are case managers within their offices. And in partnership with the primary care physicians, the Aetna case managers are helping do exactly the kind of care coordination and communication that Linda was talking about.
Let me just ask a question, you know Nico sort of was leading up to this. Why is this concept getting so much currency under health reform? What makes it so attractive?
PRONK: Well, again, I think that from both the health promotion and disease prevention perspective, and in thinking very broadly about what a medical home represents, I think really the context of current health system reform, it has the promise and I think brute evidence behind it that can actually address cost issues so it lowers costs. It makes the care side more affordable, which is of course a major objective. Secondly, it actually enhances the experience of the patient which is a component as well. And it adds to the quality of the care provided. From my perspective, that means more health is being generated. So, it basically tackles three key components of health system reform today.
BARTLETT: Linda, I know you've been involved in building these community health centers.
ROSENBERG: Yeah, we have and there's tremendous interest out there. I think the other thing it does for us I think in this country…the other appeal it has obviously is the cost containment appeal. I think that's what Nico was saying as well. We're trying to get a handle on the escalating health care costs of this nation, and we know one of things that tends to happen is overutilization of unplanned hospitalization, utilization of specialty care, very expensive tests. And there is the hope, and I think the evidence that if someone has the trusted relationship, a primary relationship with a clinician, that that reduces the reliance on unnecessary tests. It would bring down hospitalization. For us, with people with serious mental illness, what we believe is we can turn those 25 years and begin to decrease that number and begin to get increased longevity with lower costs actually, because most costs come either at end of life or because people have chronic diseases with multiple illnesses. I mean 75 percent of our health care costs are driven by four or five percent of the population. So, I think medical homes also got currency around chronic care conditions and the coordination of that as well.
BARTLETT: Can you give me an example or two of patients for whom this has actually worked Where you've seen a real difference?
CANNON: I'd say there's talk about a couple of different categories of patients. Let's say I'm seeing a patient who is having headaches or stomachaches, or missing school and it seems pretty clear that it's a behavioral health problem-that the patient may have a genetic predisposition to depression. We think it's depression, but often families are resistant to that diagnosis.
So I'll be seeing that family and if I were to say to them, "I really think your child's depressed, and we should seek some therapy for treatment," they might be resistant to that or they may not be willing to leave the practice. But if I say, "I'd like you to see Quincy next week so that she can help you figure out how to deal with these headaches and stomachaches that must be causing a lot of stress." And she'll spend an hour with them, and by the time you're done with her for an hour, they'll be asking for more.
Another example which would be a little more common would be a patient who has a problem, needs some treatment, and wants some help. I can refer them to the person within my site. They can get in within a week. They're going to see someone who is part of my team. They are going to the same office, see the same receptionist. They see me in the hall while they're there, and the nurse/care manager will call them a week after that to follow up on their visit. So, for those that are wanting to get better it's straightforward. It's helpful. For those who are avoidant or have other difficulties, it's helpful.
BARTLETT: Linda, how about for the population that your organizations deal with? Any patients that stand out?
ROSENBERG: Yeah, we have a number of our member organizations that have begun to bring some primary care capacity into their organization through a partnership, actually, with the neighborhood health center-their federally qualified health center. So, one example which is very common for people with serious mental illnesses is that they are the biggest users of cigarettes and have, you know, a sedentary lifestyle. And in one center, they brought not only a nurse practitioner in to do some initial screenings to track people's weight, body mass, blood pressure, but then that nurse practitioner is able to say, "Hey! You know there's a health center down the block and, guess what? Your case manager, John, will drive you there. And you're going to see my friend, Dr. Morrow, who is really good, and I'm going to be talking to Dr. Morrow, and you and I can talk together about what the next steps are."
And before, what used to happen is they would do an evaluation and say, "You're overweight, go see a doctor and bring us back some information when you get it." And of course, in a large percentage of cases, no one ever went nor did they bring back any information. So it's a much more active stance, really its taking responsibility, I think, for the people that you're serving.
BARTLETT: The whole person.
ROSENBERG: Exactly.
Female questioner over phone: Have the panelists or have you at the conference identified or addressed the overall financing challenges that might be involved in trying to promote medical homes across the system?
BARTLETT: Well, I'll let each of the panelists address that in turn, and then, maybe, I'll add a comment or two. Wayne, you deal with this, I'm sure.
CANNON: Well, it certainly came up regularly during the conference. I don't think the goal of the conference was to solve that. I think that what's coming out of it is there are sustainable models with a lot of improvement without huge changes in financing. If we wait until things change as far as financing, we're going to be waiting longer than we'd like to do things. So, there are improvements and things that can be incorporated in the medical home and the behavioral medicine area without waiting for finance change that has been discussed.
BARTLETT: Linda?
ROSENBERG: Yeah, we've had, as Wayne said, a robust discussion in this area and gone so far as to discuss things like bundled rates and capitation possibilities. Again, saying that the health care professional in a primary care practice in a medical home-the primary care doctor-has to be able to support these relationships with other parts, whether it's a care coordinator, or sending someone out to get exercise, or diet, and that has to be built in. But there will be savings, very clearly from not using high-end expensive services. And so, that needs to be looked at, and we have had some discussion about it. I think it's the same discussion that's going on right now in Congress and that the administration is dealing with in terms of trying to take down money from places where we think there may be some overuse like hospitals, and trying to introduce health information technology and preventive classes that in the end will save some money.
BARTLETT: How do your services prevention/health promotion usually get paid for, and what would be the challenges bringing them into the patient-centered medical home?
PRONK: Yeah, that's kind of how I was going to answer the question is in that context, because typically, these are not paid for at all. It's the individual that pays for them, or the employer. And so, I would actually agree with earlier comments, that waiting until the payment reform has all been figured out is probably a mistake. Starting with strong leadership and taking action is a good idea, but it then has to be followed with a payment reform that allows you to get to the objectives of the medical home. And to do so, I think that eventually, the payment reform will need to sort of recognize that at least part of the overall payment needs to be related to taking on responsibility of the health of the population, rather than just paying for the tasks that are being done.
So in that context, it becomes possible, it becomes organizationally relevant, it becomes financially relevant to start thinking about prevention in a different way, to start optimizing the use of community-based resources or extended services that allow you to get to underlying reasons and drivers for ill health. So, you asked earlier about an example, we have an example person who was referred to our health coaching program out of the clinic. A diabetic who was in poor control, overweight, tobacco user, physically inactive, lots of ill health risk factors, high blood pressure, and was actually referred to tobacco cessation services. In the context of the health coaching interaction, we found out that this person really wasn't ready to stop smoking, but was willing to start walking. So, over time, we engaged this person in the 10,000 steps-type program, pedometer via Web site, being able to track working with a health coach over time. The person ended up losing 50 pounds in a year and a half. So 50 pounds after a year and a half, basically has the diabetes under control.
BARTLETT: We had an excellent presentation last night by the corporate medical director of USAA, the insurance company in San Antonio, TX. And he has basically, with the support of senior management, been building a culture of health within USAA affecting all of their employees and now reaching out to the children and dependents of their employees. And their health care strategy is: let's keep people from getting sick, because, once they get sick and they go to the hospital, they spend a lot of money, so let's keep them out of the hospital. His company, he gave some examples last night, whereas traditionally their medical costs had been going up 10 percent a year, the last couple of years (and this program's been in place four or five years at this point) they only went up one percent, so management is delighted. So, there's some interesting, provocative kind of examples out there. Go ahead.
BARTLETT: Another question?
Margie Fray: Hello, this is Margie Fray with AARP. I'm just curious as to how you get all of these groups of doctors to come together and participate in this. Is there a challenge in doing that, or is it pretty easy to get doctors to come together in these medical home assignments?
BARTLETT: Well, um, I would say that The Carter Center is a great place to convene a meeting like this. It's sort of non-partisan. People come and feel very comfortable here, and I guess that emanates directly from President Carter and his long tradition of conflict resolution and working on those kinds of problems. You know frankly, the biggest problem is getting people, and I'm speaking only as somebody working at The Carter Center, is getting on their schedule early enough.
What we found is that everybody, and we have representatives from primary care, behavioral care, health prevention and promotion, was very interested in coming together and talking about this. I guess I'd characterize it, and the panel should feel free to talk about this. I think that discussion has been very collegial. It's been very productive. It's been very energetic, and we expected some serious action steps and ongoing processes will come out of it.
In terms of how to get physicians to basically agree on something…I think that, in my experience, physicians do really want to help people. And if you let the different physicians and clinicians, I don't mean to focus in only, I think social workers want to help people and psychologists want to help people. I think health preventions and promotions specialists want to help people. If you approach it from the construct of "How can we do the right thing by the people we're serving here?" you can usually get some consensus. You might not agree on every little detail, but putting caring at the center of your discussion, I think is a good way to approach this. Anybody else have some thoughts about how to do this?
Female questioner over phone: I was just wondering if Dr. Cannon gets any resistance from doctors in his own area or if everyone that he works with in the pediatric world seems to come together and want to do this or are there challenges?
CANNON: Well, I work with pediatricians, internists and family physicians. The challenges are inertia and leadership. I would say, as we look at our outcomes and we look at cost, quality, clinician satisfaction and patient satisfaction, the most dramatic improvement is in the satisfaction of physicians and other people that work with the patients. So, it's always a little difficult implementing anything new. It's not really resistance. It's just finding the time to do it. So, there's something that people are very happy about it you really have to have a good leader and you have to have enough time to overcome the inertia.
BARTLETT: We're coming to a close. Does anyone have one last quick question? If not, then I would really thank you for giving us your time. If we can assist in any way, you can clearly contact us through Paige, and I guess one of the things I'd like to point out is that one of the major reasons we're holding this meeting here is that in the fall, Mrs. Carter will be having her 25th anniversary Mental Health Policy Symposium. This year is going to focus on health reform and so, clearly, one of the areas that we do want to focus on is the medical home.
We also want to focus on information technology and comparative effectiveness all around the construct of "How do we integrate these different discipline silos (primary care, behavioral care, health promotions and prevention) into an organized, coordinated delivery system that works for people, the insurance companies, and I guess it works for doctor's too, but particularly for people. So, we will be following up on the results of the discussion today and the ongoing work in this area at Mrs. Carter's 25th annual symposium in November, and we'd love to brief you on that as well. Thank you so much for your time.
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