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Medical Homebodies’ Social Phobia

Posted By Barry Jacobs, Thursday, October 9, 2014

Dr. Jacob's post is the third in a 3-part series leading up to the 2014 CFHA Debate at the Conference in Washington DC. The debate will present major issues that have yet to be clearly resolved in the professional literature.

What’s wrong with American healthcare can’t be fixed by office redesigns, personal physicians or other hallmarks of the much-hyped, slow-to-deliver Patient-Centered Medical Home (PCMH). Integrated team-based care is nice--especially if you’re a professional who likes chilling with other professionals--but it hasn’t yet bent the cost curve. New quality improvement systems have made scant difference. It’s because what ails American health is bigger and badder.


It’s the social environment, stupid. And it’s our current blinkered hubris to believe that primping the pods and priming the processes of where most of us work—namely, primary care offices—is going to produce revelatory societal change.

New quality improvement systems have made scant difference 


That conclusion seemed obvious to public health experts Elizabeth H. Bradley and Lauren A. Taylor in their noted 2013 book, The American Health Care Paradox—Why Spending More is Getting Us Less. They pointed out that the evidence that medical homes save healthcare systems money is nebulous and inconsistent. (To wit, see the May 2014 JAMA review by Friedberg of the three-year results of 32 medical homes that were part of the Southeastern Pennsylvania Chronic Care Initiative; no cost savings and only limited improvements in quality.)


Bradley and Taylor posited instead that it is social causes of human misery—e.g., substandard housing, food deserts, lack of transportation, underemployment, chaotic families, dangerous neighborhoods—that are responsible for our middling healthcare outcomes on nearly every measure because the United States earmarks far less money per capita for basic social supports than do other countries. Poor children who don’t eat well will have poor health regardless of how many EMR-templated flow sheets we use. Hobbled, isolated seniors who can’t easily climb stairs to the medicine cabinets where their medications are located won’t benefit much from office-based medication reconciliation.

Social causes are responsible for our middling healthcare outcomes

It is daunting to address our culture’s myriad and complicated social problems. It’s much more comfortable and gratifying for healthcare professionals to target what’s within our easy reach. I’ve worked in the same innovative family medicine office in a socioeconomically mixed Philadelphia suburb for 20 years. We became an NCQA-accredited PCMH in 2009—one of the first on the East Coast. (We were one of the 32 practices in the JAMA study.) I’ve been thrilled by the changes that the PCMH has wrought—more integration, more accountability, more thoughtfulness and passion about every aspect of how we provide care. And we have plenty of improvements in diabetic and other medical indices to point to. But we have no proof as yet that the health of our patients is discernibly changed or that their overall healthcare costs are declining.


We Medical Homebodies need to look out the window upon the greater social world with its much more convoluted ways and processes. Better yet, we need to get out of our insular, cherished offices.


Dr. Jeff Brenner, a 2011 CFHA conference plenary speaker and a bonafide healthcare genius (see his 2013 MacArthur Award), has bolted the office to grapple with the social determinants that are the main drivers of exorbitant healthcare costs. His super-utilizer model of interdisciplinary team-based, intensive care coordination does several things that the PCMH does not:


--It focuses precious clinical and case management resources on the highest utilizers of hospital and emergency room services because addressing the biopsychosocial problems of those individuals is the quickest way to lower their utilization and healthcare expenditures.

--It seeks to forge lasting partnerships between facility-based healthcare providers and community-based social service specialists who are in the best position to marshal community resources for our most complicated cases.

--It embraces trauma-informed care, addictions medicine and patient empowerment as foundational tenets of the care it provides.

--And it addresses patients’ needs in all settings where they find themselves—medical offices, hospitals, sub-acute rehabs, at home, and in homeless shelters—because that is the most effective way to establish reliable healing relationships for those tossed about from one healthcare provider and facility to another.

And where is the gold standard research that Brenner’s super-utilizer model really meets the Triple Aim? It’s on its way. Brenner invited researchers from JPLA, a research group from MIT’s economics department, to do an 18-month, randomized control study of his super-utilizer programs in Camden, New Jersey to prove or disprove that they really lower costs. That study will be completed within the coming year.

An earlier study in Camden looked at the top 35 emergency room super-utilizers who rang up $1.2 million per month in charges in that city’s 3 hospitals. After a year of Brenner’s super utilizer team interventions, the costs for those same patients decreased to $531,000 per month. 

Where is the gold standard research that really meets the Triple Aim? 


Brenner’s work has also inspired other health systems to try their hands at super-utilizer care. A group of five of these systems, including my own Crozer-Keystone Health System, formed the South Central Pennsylvania High Utilizer Learning Collaborative 2 years ago and recently pooled their data. According to a white paper which the group will release in October 2014, the group provided super-utilizer care to a combined 138 patients and decreased their inpatient utilization by 34%.

In truth, I believe that we need the home base of a well-oiled PCMH working in close tandem with nimbly mobile super-utilizer teams to cover the office world and the real world. That’s the only way we can provide the flexibility of care to meet the mundane and complex demands of average and outlying patients. That’s the only way the under-achieving PCMH can possibly live up to its fulsome hype.


Barry J. Jacobs, Psy.D., Director of Behavioral Sciences for the Crozer-Keystone Family Medicine Residency in Springfield, PA, has been the lead faculty member for the past 2 years for the 2 super-utilizer programs that are run out of the residency’s primary family medicine office. 


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David Seaburn says...
Posted Thursday, October 9, 2014
Barry: This is a fabulous blog! Should be a commentary in a journal. Terrific stuff. I agree that it has to be both. But I must add, since I now live in the real world of healthcare rather than the rarefied world of university medicine, there are precious few healthcare providers or systems that even do well at the most basic approaches to healthcare---communicating with each other (even when specialists are face to face), communicating anything to patients (from who the provider is standing at the foot of the bed to what meds are being prescribed and why, to whether there is a discharge plan) and not only not communicating with family but basically being annoyed with them. I have been amazed at the costly and poor healthcare provided to my mother and mother in law in recent months, not to mention the nearly incompetent judgment of my own primary care office in treating a simple healthcare problem that our daughter recently had (which became an unnecessary and costly waste of time). It is as if none of the important work that has been done by all of us over the years has reached beyond the university med centers. I am sure I don't have the whole picture, since I have been out of the loop really since I left Strong in 2005. But I think the average patient would be surprised to hear that any of this work is being done. Sorry to be somewhat grim, but I think our healthcare is pretty awful. I hope that what you are writing and describing does reach the community. It has to.
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Larry Bauer says...
Posted Friday, October 10, 2014
Nicely done and said.

While I am not a great fan of the PCMH as defined by NCQA I do think there is now robust data reporting efficacy when properly implemented.

But the real issue for me is what outcomes matter. The focus on process measures like Hemoglobin a1c is largely a silly measure. How about does the PCMH reduce admissions to the hospital. Will a FP or NP be allowed to make a home visit if it would help a patient stay out of the hospital? Forget readmissions when the real issue is unnecessary admissions in the first place.

If we focus on patient outcomes that matter, then paying attention to their social support becomes important. Also the assistance for patient’s whose social supports are in disarray does not need to come from the PCMH but the PCMH can play a role in aligning with the social and family supports that can influence a patient’s life and well being.

Everyone believes things can’t be done because there is no code to charge the insurance company for the service. Time to get past that issue. That is where the real change can happen.

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