States eye primary care pilot projects

States eye primary care pilot projects

June 14th, 2010 by Emily Bregel in Health

Heath care leaders in Tennessee say they are open to participating in pilot projects seeking to repair the nation's fractured primary care system but say it's too early to talk specifics.

Georgia officials are less forthcoming.

"We will certainly look at any and all projects that could help Georgia doctors provide better care for our citizens, but the term demonstration project usually means that the federal funding soon runs out and the state is left to pick up the tab," said Bert Brantley, spokesman for Gov. Sonny Perdue.

"We will look at these carefully but proceed cautiously to ensure the state isn't stuck with the bill," he said.

Staff Photo by Dan Henry/Chattanooga Times Free Press Dr. Steve Adams, a primary care physician at UT Family Practice, reviews an X-ray to find a fracture on his patient's foot.

Staff Photo by Dan Henry/Chattanooga Times Free Press Dr....

The March federal health reform legislation included provisions to put primary care physicians back at the helm of patient care and to pay doctors to keep patients healthy, rather than for treating them when they are are sick.

"There is an enhanced focus almost at every level -- at the national level, from insurers and health care provider organizations -- on truly this concept of a 'medical home,'" said Dr. Wendy Long, chief medical officer for the TennCare Bureau.

The phrase refers to the primary care provider acting as a gatekeeper to a patient's medical care.

The TennCare Bureau is considering a number of demonstration projects offered under health care reform, Dr. Long said.

"We certainly agree (that) the concept ... is really a cornerstone of good, quality medical care," she said.

Some local doctors are unconvinced that a few pilot projects will make much difference without major changes in how health care is paid for and delivered broadly.

"It's not clear to me that the change is coming immediately or will come at all," said Dr. Stephen Adams, director of the family medicine residency program at the University of Tennessee College of Medicine in Chattanooga. "I don't think this bill that was passed is going to be the big fix."

Demonstration projects are looking at new ways to provide primary care, such as encouraging collaboration between doctors and hospitals, offering higher payments for providing coordination of care and encouraging outreach to patients with chronic illnesses or infrequent doctor visits.

Today's health care system is so fragmented, doctors have a hard time keeping up with patients' hospitalizations, prescription drug usage and visits to specialists, Dr. Long said.

"Many years ago, if you were hospitalized, it was probably your doctor that hospitalized you," she said. "But today ... a patient can go into a hospital and come out and their primary care provider would never know about it."

Insurers' fee-for-service reimbursement structure doesn't provide incentives for doctors to focus on quality care, Dr. Adams said. Proactive care is costly in a time of tight profit margins, he said.

"Right now we're paid kind of like somebody making shirts in a factory. You get paid per patient, per day," Dr. Adams said. "To do it right, you need staff who can spend time digging through charts and look for patients who are falling through the cracks, reaching out and calling patients who aren't showing up."


Some medical experts argue that reform won't help if a fundamental problem isn't addressed: a shortage of primary care doctors.

The problem will worsen as older doctors retire and as millions more patients are covered under reform, they say.

"There aren't enough primary care physicians now, and there aren't going to be in the future," said Diana Allen, CEO of Primary Health Care Center, a nonprofit that has community health centers in Trenton and Rossville in Georgia.

"It seems to me they've put the cart before the horse," she said. "You've got to train enough physicians to begin with, and that's not happening now and there's not plans in place to do that over the next 10, 20 years."

Others worry that proposals to boost Medicare payments for primary care, and eventually make Medicaid payments at least equivalent to Medicare rates, are overly optimistic.


The federal health care reform law has several provisions dealing with primary care:

* Adds $11 billion over five years for federally qualified community health centers.

* Guarantees that new health plans will cover all preventive care.

* Creates a center for demonstration projects within states, including projects strengthening primary care.

* In 2011, Medicare payments for primary care will increase by 10 percent. In 2013, Medicaid payments must be at least 100 percent of Medicare payments for primary care physicians.

* In 2012, demonstration projects will test "bundled payment" models of paying all providers involved in an episode of care.

Source: Commonwealth Fund analysis, April 2010

"They're saying primary care is going to get an extra 10 percent (in Medicare payments under) this health plan," said Dr. John Antalis, family medicine specialist in Dalton, Ga. "But what I see now is very grave concerns about the ability of this health care plan to actually work because of the huge costs it is going to take to implement it."

Health reform pilots are similar to a BlueCross BlueShield of Tennessee initiative already under way in the state, said Dr. Thomas Lundquist, vice president of performance measurement and improvement at BlueCross.

The health insurer is leading a "patient-centered medical homes" initiative, in which physicians and practices can get extra funding to provide better primary care.

Through grants, doctors can buy health information technology, hire workers to reach out to patients with chronic conditions and reimburse for patient interactions other than office visits, such as e-mails and phone calls, he said.

"I think the reform act is trying to encourage innovation and strategies that improve quality and also addresses the cost-efficiency element of care," he said. "They're looking to the private sector to identify meaningful pilot projects and demonstrations and designs of care that will allow us to get meaningful" systems set up.

Three of the state's 20 patient-centered medical home sites are affiliated with Erlanger hospital.

Thought it's early to tell, the initiative and a team-based approach to care have promise, said Dr. Alan Kohrt, medical director of T.C. Thompson Children's Hospital, which will be one of the participating sites.

"This is no longer about the physician doing everything himself," he said. "It's just a different way of doing business. It's a different way of providing care."

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