For over 4 years, my practice consisting of a solo Endocrinologist along with well-trained CRNP/CDE and Medical Assistants, have been providing care to about 5000 diabetics in a three-county area of PA. We have developed a “continuous care model” for successful management of diabetes. We have effectively used IT to achieve superb results (much better than larger practices). Of course we don’t have the resources to conduct a formal study to prove our effectiveness. But the word from our patients and that of local ER docs that lament that they don’t see hardly any of our patients in their ERs, provide us with fairly strong anecdotal evidence of the effectiveness of our strategy. However, it is been impossible to convince payers to simply take a look at our success, let alone think of getting paid for all this.

Having personally helped the ACP craft their PC-MH program, I am quite disappointed that there is no provision for sub-specialists with the knowledge and resource to be a medical home to participate. This rigidity of thought is truly sad because it impedes innovation in medical care. Further, unless we move away from a inflexible CPT-based reimbursement system, there will be no room for rewarding better care.

Two weeks ago Secretary Sebelius announced “Medicare to Join State-Based Healthcare Delivery System Reform Initiatives” http://www.hhs.gov/news/press/2009pres/09/20090916a.html in a joint press conference with Vermont Govenor Jim Douglas and White House Reform leader Nancy-Ann DeParle. Although there is a lot to be worked out in the concept . . .

The transcript from the event makes clear that community health teams are part of the discussion. http://www.vermontbiz.com/news/september/douglas-white-house-over-medical-home-plan-modeled-vermont-blueprint

The Secretary commented,
“Patients just don’t [get] care from their doctors in this plan. They also get care from community health teams, staffed by nurses, social workers, and behavioral health counselors who check up on patients to make sure they’re managing their chronic conditions.”

However, our experience at the John A. Hartford Foundation suggests two issues that need to be addressed for this to work.

1. All of these health care providers need additional expertise in geriatric care. Caring for 85 year olds with multiple conditions is not the same as caring for a 55 year old with diabetes. Most health professionals are not familiar with many basic issues in geriatric care and are therefore not prepared for their roles.

2. Forming teams is very difficult. It takes time, structure, and specific skills. Again, health care training provides very little preparation for this way of working.

Great ideas take strong implementation.