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Medical Home: changing the rules of primary care

May 30, 2010 | By Swedish Medical Center More

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It’s mid-afternoon in Caffe Fiore on Ballard’s Leary Avenue, and the soft autumn light adds its warmth to an already inviting setting. Behind the counter, baristas serve steaming coffee to a steady flow of customers who are pushing strollers, chatting with friends, or intensely focused on the laptop screens in front of them. The baristas are all in their 20s. They are cheerful, hardworking and – until recently – among the millions of Americans who might have insurance to cover a catastrophic illness, but can’t afford the primary health care it takes to stay well.

Dr. Miranda Lu counsels with a patient at Swedish’s Community Health Medical Home in Ballard.

“Our business is too small to be able to provide health care for our staff; our first priority is making sure we can pay their wages,” said Katrine Callahan, Caffe Fiore’s general manager. “We are always looking for ways to help them out, to get them care. What we want for ourselves and our staff is a doctor who knows us when one of us walks in the door. I want someone who is actually concerned about helping me stay healthy instead of waiting for an issue to come up and then trying to fix it. But how could we afford that?”

Katrine was surprised to find the answer a few blocks away on Swedish Medical Center’s Ballard campus. The recently opened Swedish Community Health Medical Home was designed to provide the community with unprecedented access to primary health care.

The word is spreading as friends tell friends: The clinic space is beautiful – large, light-filled and calm – but the waiting room is small because, well, there’s really no waiting. You can request appointments online and get seen within a day. When you call the office, a real person answers, and if you have a medical question, the doctor calls you back.

For $45 a month, Katrine learned, she could:

Come in for an unlimited number of appointments
Expect each appointment to last as long as she needed
Schedule same-day or next-day visits
E-mail or talk to a physician outside clinic hours
Log onto a secure Web site to review her medical chart, e-mail her doctor or make an appointment
Have routine tests and lab work done in the clinic

Swedish Community Health is a pilot program, built on a model called the patient-centered medical home. While many clinics across the country are converting existing programs to this model, Swedish is one of the first to start with a vision for accessible, affordable primary care and then build the clinic from the ground up.

The focus is on wellness, disease prevention and day-to-day management of chronic illnesses. It is an approach, Swedish believes, that will be more convenient and affordable for patients, improve health outcomes and help reduce out-of-control health-care costs.

New Concept, Old Fashioned Care

At the heart of Swedish Community Health is an old-fashioned concept Katrine’s generation is too young to remember: Doctors who have the time to pay close attention to their patients.

“At my first appointment, I was really surprised that my doctor spent a full hour with me,” Katrine said. “In other places, I’ve typically gotten 10 minutes, if that. I’m pretty healthy, but have minor recurring concerns, and have been having a difficult time getting any consistency with health care. I talked with Dr. Lu about that and other ongoing concerns. It’s clear that the goal is to prevent issues and keep me healthy. That’s the most natural concept I’ve ever heard, but for some reason, it’s a ‘new’ concept.”

Miranda Lu, M.D., said consistency, communication and tracking patient information are all keys to facilitating optimal patient heath. The clinic’s doctors build time into their daily schedules to make follow-up calls to patients, especially those who are medically complex. The physicians also take turns being on call outside regular clinic hours.

In addition – thanks to a seamless system of electronic health records throughout all of Swedish – the staff can keep close tabs on patients who are hospitalized at Swedish or referred for specialty care. Although much goes on behind the scenes, what patients seem to appreciate most is, simply: Time.

“I had one patient with a heart-pounding sensation who had been to the emergency room, multiple doctors and a cardiologist,” Dr. Lu said. “It turned out that an over-the-counter medication was causing the problem. She had been using a nasal spray for over 20 years, and had never thought to mention it as part of her medical history. We were 30 minutes into our conversation when this came up – and I know that if I had seen her in the typical clinical setting, we never would have gotten to it.”

One might think that such access to a physician would result in unnecessary calls or appointments, but so far, that’s just not the case. Because they know they can reach a physician when they need one, Dr. Lu noted, people are not clamoring for time or services they don’t really need.

Pioneering Payment Reform

Dr. Kendra Wiggins with one of her younger patients; the clinic sees patients of all ages

Intuitively, it makes sense: If all primary care doctors had abundant time to listen to their patients, make follow-up calls, or see three little boys in one appointment, considerable time and money could be saved. Unfortunately, across the country, the opposite is true.

“We believe the prevailing fee-for-service model is part of the problem with primary health care today,” said Jay Fathi, M.D., a family physician and the medical director of Primary Care and Community Health at Swedish. “With this model, to make money, you have to see as many patients as you can, spend as little time with them as you can, and charge payers as much as you can. Even if it’s a two-minute question, the system creates the incentive to have patients drive in, pay for parking, wait for the doctor… The time has come to be innovative. We think the payment rules should change.”

The Swedish team realized early on that the pay-for-service model was at odds with its patient-centered vision. Instead, they created a new reimbursement system and started this medical home pilot with an option for patients without insurance coverage to pay a flat monthly fee for all medical services available in the clinic. Doctors are paid a monthly salary not connected to patient volume. Self-pay patients – like Katrine and many of the café’s young baristas – have the monthly fee automatically charged to their credit cards.

Swedish physicians and administrators had expected to find a demand for affordable primary care, but were still surprised to find that, at the six-month mark, 40 percent of all Swedish Community Health patients are self-paying. Another 15 percent are Medicare patients, and about 10 percent qualify for Swedish’s charity care program. Swedish is partnering with Molina Health care, a third-party administrator for Medicaid, to provide the care for the remaining 35 percent of the clinic’s current patients.

Thanks to a recently signed partnership agreement with Premera Blue Cross, another component is being added: patients with private-pay insurance. Under the agreement, Premera will pay a monthly fee for every member enrolled in the program, and Swedish will waive their co-payments.

The clinic expects to grow to a total patient population of 2,500. Of those, an estimated 800 to1,000 patients will be Premera members.

The agreement also includes additional financial incentives for meeting evidence-based standards, such as immunization and screening programs and lower blood pressure rates among patients with hypertension and optimal blood-sugar levels for patients with diabetes.

“This is an innovative way to reimburse for primary care, and will help prevent such things as renal failure, stroke and heart failure down the road,” Dr. Fathi said.

Challenges Ahead

Swedish is charting new territory with the way it has created this patient-center medical home, and questions remain: What is the best way to ensure specialty care for services beyond the scope of the clinic? Will the percentage of charity care patients rise, straining the system? Will a growing shortage of primary care doctors make the clinic challenging to staff as the patient load increases? What changes will national health care reform bring?

Any bold innovation brings its share of challenges, and not all the answers are readily available. Granted, in the complex conundrum that is our national health-care crisis, Swedish Community Health may be just one small step in the right direction. But it is a step that is working for its patients, and for its staff.

“This is why I went into primary care – to be able to take care of the whole person,” said Dr. Lu. “It’s a challenging job. It keeps us on our toes. But we have a great team here, and we are making a difference in the lives of our patients every day.”

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