In a continuing series, the Crested Butte News is looking at what’s happening on the local stage to provide affordable, quality healthcare to the valley. Last week, we looked at the big picture and the ways that rising health care costs are straining the healthcare system. This week, we look at the type of care local providers are striving to provide—a model that puts patients first.
When Dr. Eric Thorson and his wife, Marsha, developed the way the Town Clinic of Crested Butte would operate, they envisioned a level of care that went beyond the clinic doors.
Patients would be able to correspond with Dr. Thorson securely by email, and make appointments and see their lab results online. Clinic staff would follow up with them after appointments, and treatment decisions would take into account the patient’s overall health and life circumstances—what kind of treatment he or she could afford; whether their work schedule or access to transportation allowed them to travel for further treatment.
“One of the things that was really important from the beginning was to make it patient-centered. That’s one of the driving forces in primary care, to do things like a patient-centered medical home. It puts the patient at the center of the focus as opposed to revolving around the doctor or the clinic,” Dr. Thorson said.
“Or even a particular piece of the patient—not just focused on diabetes or on obesity,” added Marsha Thorson. “It’s taking into account everything going on with them… making sure everything is where it needs to be when it needs to be for the patient.”
Dr. Thorson schedules longer than average appointment times—30 to 60 minutes—and the clinic is open Thursday through Monday. Patients can schedule appointments on weekends and weeknight evenings, although that feature is taking a little longer to sink in. Mondays tend to be busy, and patients will tell Dr. Thorson they got sick on Friday but waited to see him because they didn’t know about weekend appointments. But after more than a year in service, the Thorsons and Town Clinic staff feel they’re making a connection with the community.
“Some of the voicemails that come through, people are actually addressing specific people in the office thinking that’s who they’ll deal with,” Marsha Thorson said. “And they are. It’s true. People are comfortable knowing who is in this office.”
By acting as a “medical home,” Dr. Thorson’s primary care clinic represents one facet of what industry experts call integrated medical care, a form of care where care is coordinated by the primary care physician and information flows more freely from primary care to specialty services to rehabilitation and back to primary care. This model often results in better, more cost-effective care—and it’s something healthcare providers are beginning to pursue in the Gunnison Valley.
“Because of a lot of factors in an advanced medical home model, where the provider and patient are connected by a secure electronic portal, care can sometimes be done out of the office for such things as management of chronic diseases and routine primary care activity,” said Michelle Campbell, who joined Gunnison Valley Health last October as the chief marketing and business development officer. She has more than 17 years of experience in healthcare marketing and consulting.
If patients can email their doctor their symptoms, Campbell explained, they might be able to avoid an office visit. And if that clinic is integrated into a larger healthcare system, connected by technology such as electronic medical records, then patients’ records follow them from their primary care doctors to specialists. There is one patient history and one medication list, and things are simplified for the patient and the provider. Information flows through the whole system more seamlessly.
“In an integrated system, where physicians are compensated for serving a population and improving overall health instead of being compensated for an episode of care, people are looking to manage the primary care of a patient in a way that’s cost effective, and then extend that into specialist care so that you’re improving cost efficiency as well as the overall health of patients across the care continuum,” Campbell said.
The idea of integrated care is not new. In a 2009 article for the New England Journal of Medicine, Dr. Francis J. Crosson wrote that the Committee on the Costs of Medical Care recommended a group-based approach to medical care in 1933. At the time, U.S. health care expenditures were 4 percent of the U.S. gross domestic product. In the thick of the Great Depression, Crosson wrote, that sum was believed “to threaten the country’s financial recovery.”
The 1933 report recommended “Medical service should be more largely furnished by groups of physicians and related practitioners, so organized as to maintain high standards of care and to retain the personal relations between patients and physicians.”
The recommendation takes on added significance when you consider that nearly 80 years later, the United States finds itself in a similar place. A 2009 article on healthcare in The New Yorker, “The Cost Conundrum,” referred to a speech by President Barack Obama. He said, “The greatest threat to America’s fiscal health is not Social Security. It’s not the big investments that we’ve made to rescue our economy during this crisis. By a wide margin, the biggest threat to our nation’s balance sheet is skyrocketing cost of health care.”
Yet integrated models have not become the norm in spite of examples that show cost efficiency and better patient care go hand in hand.
Better communication, better standards of care
In 1998, a group of physicians—including current GVH board of trustees chair Dr. Bob Brickman—published a study that looked at “process improvement” in an integrated delivery system, Sentara Health System in Norfolk, Va. (Dr. Brickman then served as medical director for Sentara). The study sought to improve care for several diseases, including community-acquired pneumonia and strokes, by increasing communication between healthcare providers, standardizing procedures and eliminating delays during diagnosis.
In short, patients got better faster and the cost of care went down. The study was published in The Journal on Quality Improvement and stated that for community-acquired pneumonia, “the mortality rate decreased from 12.5 percent to 9 percent, the average length of stay from 7.5 to 6 days, and the cost per case by more than $1,300.” For stroke patients, process improvement efforts decreased the length of stay from an average of 9.8 days to 5.3 days, with a cost savings of $2,000 per patient.
The New Yorker article also featured healthcare systems where increasing integration and communication resulted in better care and lower costs. In Rochester, Minn., home to the Mayo Clinic and some of the most advanced medical technology, Medicare spending is in the lowest 15 percent in the nation.
In the article, author Atul Gawande wrote, “The core tenet of the Mayo Clinic is, ‘The needs of the patients come first’—not the convenience of doctors, not their revenues. The doctors and nurses, and even the janitors sat in meetings almost weekly, working on ideas to make the service and the care better, not to get more money out of patients.”
Lower healthcare costs were simply the byproduct of patient-centered care. The same held true in Grand Junction, Colo., where Dr. Thorson completed his residency. There, the medical community adopted a patient-first approach to healthcare during the 1970s.
“They did some unique things to ensure that people with all different types of coverage were getting access to care that was affordable, and they were able to be seen by a provider in the community,” Dr. Thorson said. “Medicaid does not cover the cost for me to see a patient, but in Grand Junction they pool a lot of the funding together so that patients on Medicaid have access to providers, and those providers are reimbursed at a level similar to private insurance reimbursement.”
The New Yorker article also pointed out that doctors in Grand Junction meet regularly for peer reviews, implemented at the request of the local health plan provider to study everything from poor prevention practices to unnecessary surgeries. And in 2004, they created a community-wide system for sharing lab results, patient data and office notes. The result is one of the lowest-cost markets in the country.
Integration in the Gunnison Valley
One of the primary examples of integration in the Gunnison Valley took place after GVH took over management of the Senior Care Center in 2008. At the time, the facility had an annual operating loss of more than $100,000. But at the recommendation of a consultant, GVH integrated several silos within senior care: home health, palliative care, hospice care, senior care and assisted living.
“By integrating we reduced cost and that has in some measure allowed us to be in the black,” Dr. Brickman said. Full facilities and the right combination of paying residents have also played a roll.
Integration has also set the stage for better care. In Gunnison, Dr. John Tarr is chief medical officer at GVH and consults with seniors’ attending physicians. From a clinical standpoint, he said, integration has great promise for patients because they’ll have access to a full spectrum of medical services—from EMS to hospital care to the nursing home and everything in between—without any “siloing” of information.
“Having the whole package under one governance makes sure all organizations are working toward the same goal, which is the most appropriate care for the patient, regardless of the extent and stage of illness and health. It ultimately has not yet achieved the level of functional integration I would like to see but it’s progressing down the road,” Tarr said.
One of the biggest barriers—for which there is an implementation plan—is integrated electronic health records. But doctors are already holding weekly case conferences with home medical services to make sure clients receiving home health services, hospice and palliative care are getting appropriate care without duplication of services or other problems.
“The infrastructure is in place here to really facilitate integration, and in my opinion, make this a model for the way healthcare ought to be delivered,” Tarr said.
GVH taking leadership role
In addition to integrating senior care, GVH has also taken a larger role in making sure the valley has access to primary care. At the start of the year Gunnison County had nine primary care physicians. But to account for decreases, like the closing of Dr. Joanne Huntington’s office, GVH projects that 2.5 primary care positions need to be filled. To help account for that, GVH arranged for a temporary doctor to fill a vacancy in Dr. Jay Wolcov’s office in Gunnison and has been recruiting physicians to work for the hospital. Two primary care doctors—a husband and wife team with specialties in rural medicine—are expected to start on June 1. A medical student loan program also provides incentives for primary care doctors to work in the Gunnison Valley.
“The only entity in the valley that can ensure [adequate access to primary care] is the healthcare system,” Brickman said.
In most cases, independent primary care clinics can no longer recruit new doctors because graduates are not in a position to buy into a practice. As discussed in Part I, their debt is simply too high.
But GVH is trying to do more than fill positions; leaders are also looking for ways to connect practitioners across the valley, whether they work for the hospital or not. Campbell explained that any integrated approach to local healthcare must be a mixed model, because both GVH and independent practitioners serve the valley.
To that end, GVH hosted a meeting with local physicians in December 2011 to talk about ways to increase integration. They’ve even met with Dr. Thorson to discuss ways to support his unique business model. One question concerned his hours of care. Currently, if a patient needs access to radiology on the weekends, the only avenue is the emergency room. GVH is considering whether there is a different, and cost effective, way to support those types of needs.
And GVH is also talking to providers about starting a primary care service line—group conversations between primary care doctors to discuss trends in the care they’re providing. Because the valley is a mixed model, these ideas won’t necessarily lead to the same kind of standardized care that other systems, like Sentara or Grand Junction, have seen. But Gunnison Valley is a small, rural community where, Campbell pointed out, some forms of integration already exist. Primary care physicians and orthopedic specialists already serve in the ER. Leaders hope that increasing that partnership and communication can help open the door to more integrated (and cost effective) care.
Join us next week as we look at finances behind healthcare. We’ll learn how integrated care employs specific methods of payment to encourage patient-centered care, and learn how the Affordable Care Act and federal mandates play a role. We’ll end our series by looking at how individuals can navigate the insurance system and get involved in community conversations about health care.