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H&HN Daily

Navigating Over Health Care's Growing 'Chasm'

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Harvard Medical School instructor advocates for tearing apart the current primary care model and starting anew.

Editor's note: H&HN Staff Writer Marty Stempniak is blogging this week from the Mayo Clinic's Transform 2012 symposium.

 

ROCHESTER, MINN. — There's a growing "chasm" in health care, a veritable ocean that the industry needs to traverse, says Rushika Fernandopulle, M.D. And doctors must decide whether they want to stay in 1902 and rebuild their boats to cross the water, or try and invent the plane.

The practicing physician and Harvard Medical School instructor slammed the current state of primary care Monday during the second day of the Mayo Clinic's Transform 2012 symposium, in Rochester, Minn. He related the story of one patient, named Sharon, who, because of her various chronic conditions, was accumulating specialists like "barnacles on a ship," with about 12 of them, to go with her 27 prescriptions. She was costing the system $200,000 a year, he said, and still not healing.

"I don't know why we keep making excuses or tolerating not being able to provide this sort of care," he said, referring to his more ideal vision of the primary doc. "Between the health care we have and the care we could have lies, not just a gap, but a chasm."

In Fernandopulle's opinion, there are three main problems plaguing the system. Co-pays are discouraging patients from showing up. The fee-for-service model, he said, rewards doctors for not fixing the problem and prolonging the treatment. And, he pointed out, just 4 percent of the health care dollar goes to primary care. So 96 percent of what the industry does is a failure of those practices. Why not invest more of the pie into the PCP, and find savings in keeping patients out of places like the ED?

Iora Health, a firm Fernandopulle cofounded in Cambridge, Mass., has been working to reinvent primary care over the past decade or so. Iora Health's practices only work with self-insured employers, Dartmouth College being one of the big ones, so they can negotiate and earn a flat rate for their services. No money comes out of the patient's hands when they visit the doctor. The firm tried early on to work with larger health systems, he said, but those organizations were content in "ship building," and Iora had to build physician practices from scratch to test the model.

Iora puts an emphasis on using "health coaches," of which it has four for every one primary care physician, to relate with patients and intervene when they fall off track. If social needs, such as transportation or depression, are getting in the way of managing a chronic disease, the coaches can help.

"It behooves us to figure out why they're not doing what they should do," Fernandopulle said. "And shame on us if we don't figure that out. Too often, we do the easy thing and just blame it on the patient. Often it's that there are social needs that are taking higher priority, and we need to fix those social needs or we'll never take care of the medical needs."

Coaches are everyday folk who have a knack for relating to people. One of the best in Atlantic City worked in a Dunkin' Donuts before Iora hired her. Another in Las Vegas was a cashier at Target. Often patients referred candidates for the job because they had an idea of the right fit for their needs.

Sharon, the patient, was 60 years old, had raised three girls on her own, and was battling diabetes, hypertension, after-effects from a minor heart attack, osteoporosis and lung disease from 40 years of smoking. Fernandopulle and his coach dumped 20 of the medications, and fired 10 of the specialists. The two that remained had to coordinate what they were doing with Iora. He and his coach met with Sharon's family in person, arranged a plan, and shifted her to a palliative care mode. She lived another year, but only went to the hospital twice and died in her bed peacefully with her girls by her side after celebrating the holidays at home.

Besides Sharon's story, Fernandopulle ticked off results to back up his model. Yes, primary care is a little more expensive and drug costs increased (because patients actually took their pill, he says). But outpatient costs have dropped by 25 percent and ED visits by 48 percent, and net spending is down 15 percent.

Can this model be spread more broadly through the system? Fernandopulle said they're having no problems recruiting patients, physicians or health coaches. But it's the insurers where they've hit a road block. Payers are afraid of upsetting their network of doctors and of trying a different way of reimbursements. 

"I've had angry people say, 'How are you going to make whole those doctors for whom you are taking their patients?' " he said. "And the obvious response, of course, is it's not my problem, and I don't think it should be any of our problems. I think we forget often that the point of health care should be to serve our patients, not ourselves."

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