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By Robin Jay, Editorial Director

The Medical Home concept was born as a result of the Tax Relief and Health Care Act of 2006. What is a Medical Home? It’s a healthcare delivery system that provides targeted, accessible, continuous, family-centered care to high-need populations. The legislation followed federal government recognition that chronic disease accounts for 70 percent of our country’s healthcare costs. To test effectiveness of the Medical Home concept, the Act provided funding for a three-year Medicare Medical Home Demonstration Project to be launched in 2010.

The Demonstration Project includes family practice, internal medicine, geriatrics and specialty and sub-specialty practices, except radiology, pathology, anesthesiology, dermatology, ophthalmology, emergency medicine, chiropractic, psychiatry and surgery.

The typical Medical Home requires 17 basic Medical Home capabilities, including:

• A health assessment plan
• Integrated care plan
• Test tracking and provider follow-up
• Medical reviews and
• Referral Tracking

Additionally, to qualify as an “enhanced” Medical Home, project participants must use electronic medical records, coordination of care (including follow-up of inpatient and outpatient care), measures of performance, and physician reporting. Practices may qualify for Medical Home status if they use the NCQA-developed Physicians Practice Connections Patient-Centered Medical Home (CMS version) criteria.

To discuss the benefits of a Medical Home — including the vital need to incorporate behavioral healthcare for both for mental illness and substance abuse — The Carter Center hosted a Medical Home Summit at its facility in Atlanta this summer. Experts from around the nation gathered to discuss this very important topic, and four of them participated in a press conference following the event. Behavioral Health Central attended the press conference, which included moderator John Bartlett, M.D., M.P.H., Senior Project Adviser for Mental Health Program Activities at the Carter Center; panelist Wayne Cannon, MD, Pediatrician at Intermountain Health Care; panelist Linda Rosenberg, CEO of the National Council for Community Behavioral Healthcare; and panelist Nico Prank, PhD, FACSM, Senior Research Investigator and VP of Health Management at Health Partners.

To listen to the panel discussion, click on the media player on this page, or read the transcript that follows…

Dr. John Bartlett: Mrs. [Rosalynn] Carter has been a leading advocate for people suffering from mental illness and addiction for many, many years. She’s focused particularly on issues of access and improving quality of care, reducing stigma, and those have been her particular areas of interest. The bottom line is that a significant amount of mental health and addiction problems are seen only in the primary care setting. For example, about 50 million Americans every year suffer from depression. 50 percent of those never get treated at all. But of the people that get treatment, over half get their treatment only in primary care. So in a way, the primary care setting is kind of the de-facto mental health and addiction delivery system in this country, and the question really is, "Has it been designed to really do well?"

The evidence suggest that people who do suffer from mental problems, addiction, depression, anxiety don’t do very well in the primary care setting and, in fact, the primary care setting is not really designed to do well by them. Primary care physicians are seeing a lot of patients. They don’t really have time to sit and talk with people, and so, therefore, the Medical Home concept is really an attempt to modernize and transform the primary care delivery system in the country.

The reason we’re hosting a Medical Home Summit is as advocates for the mentally ill and people suffering from addiction, we’re very concerned that there’s a place at the table within the Medical Home for behavioral healthcare. We also saw the opportunity, frankly, to invite our colleagues from health promotion prevention because they also traditionally have not had a place at the table within primary care. And so we’ve been very concerned that since there’s been a tremendous amount of emphasis in the discussions about health reform around the whole concept of health promotion and prevention, that’s really been the purpose.

What I’d like to do at this point is ask each of the panelist to give a brief summary about why they came here and what they’re hoping to get out of the meeting. Nico [Prank], do you want to start?

Dr. Nico Prank: Sure. From my health promotion and disease prevention perspective, it’s actually quite exciting to be at the table and to be part of discussions and conversations, because as the design of the Medical Home goes forward, it’s important that by design, health promotion and disease prevention is represented. We know that there are multiple determinates of health. Actually, socioeconomic status of people, their social circumstance, their access to healthcare, their genetic predisposition, are all important factors, but the one that actually stands out that explains roughly 40 percent of all of this, of all of the health statuses, is related to behaviors. And so the idea that the Medical Home can become an access point for successfully accessing resources that may help people change behaviors, reduce risk factors or even give them access to services that will prevent those risk factors from even occurring, is an important component.

When you have a teachable moment, if you will, with the patient, that could be just a real powerful way to access these services across the community. From a health-promotion, disease-prevention perspective, being here and being part of the conversation so that there is an appropriate role in the patients’ end of Medical Home for health promotion and disease prevention is important. Costs of care can be reduced significantly by reducing both the need as well as the demand for medical healthcare services.

John Bartlett: Wayne [Cannon], I know that you wear two hats within Intermountain: You are a practicing pediatrician, but you also have responsibility for all the initiatives at Intermountain about primary care and behavioral care working together. So what brings you to the meeting?

Dr. Wayne Cannon: Well, you know healthcare reform is about improving quality, improving access and decreasing cost. As a pediatrician, I’ve lived through the era of fragmentation of care. It’s difficult to help our patients with behavioral health problems, and if we find help, it’s difficult to get them there. But there are models that would work very well in a Medical Home for behavioral health. There are many existing models and it’s critical that behavioral health services be part of any medical home. It just helps patients, helps practices, increases access, reduces costs.

Dr. John Bartlett: Linda [Rosenberg], you’re a social worker by training, but I know your organization is very, very involved in this.

Linda Rosenberg: We’re really interested in two directions. In one way, we know or we expect that with a Medical Home, more people will have coverage. They’ll have medical insurance as a result of the work going on in Congress right now. But those people will need a place to get their care.

We do believe that everyone needs a physician, a primary care doctor who helps them manage any illness they have, as well as helps them stay healthy whenever possible. I think one of the things Dr. Bartlett said that was very true is, this whole concept of a Medical Home really modernizes that old fashioned, family doctor process. So we’re very interested that any medical home includes behavioral healthcare specialists. We know that many people present with very serious illnesses like diabetes, cancer, heart disease, where they have co-morbid depression, anxiety and issues that need to be addressed, and you need a team of people in this healthcare home or this Medical Home that can do that.

We’re also interested in it from a perspective of people with serious mental illness. In 2006, the study that SAMHSA funded informed us that people with serious mental illnesses are dying 25 years before their peers, and that’s been a major focus of the National Council. Those people often are treated in community mental health organizations. Those organizations have the capacity to do some primary care, or more importantly, to partner with a primary care practice in their community, and so we see Medical Home as an opportunity to treat the whole person, and then of course, to move into the whole area of health promotion and prevention.

Dr. John Bartlett: So what I’m hearing you say is that in the Medical Home, it’s not just the primary care physician working alone, but she or he has access to a whole variety of other specialties. In what other ways does it modernize primary care?

Linda Rosenberg: I think the other thing from our perspective that we’re very involved with, in terms of healthcare reform, is health information technology. When you think of your old fashioned family doctor, they didn’t necessarily have an electronic health record, but even perhaps more importantly, they didn’t have systems that were able to notify you, to remind you and prompt you about the kind of things that you needed to do. Whether you’re on a diet and you need to be reminded to be measuring your calorie intake or to do your exercise that day, that physician's office needs to be able to track your blood pressure and all your health status information so they can remind you when you need to come in again. So that’s kind of a tickler system that’s really part of a whole push around health information technology. So, for me, that’s one other way to get modernized.

Dr. John Bartlett: Wayne, what are some of the differences you see in the way that primary care has traditionally been practiced? Intermountain by the way is the leading organization nationally, so maybe you can talk a little but about how primary care is practiced in the community where most people would get their care. How would the Medical Home would make it different?

Dr. Wayne Cannon: 25 years ago when I started practice, we spent most of our time treating meningitis and asthma and pneumonia. I spend my time seeing patients in the office for preventive care and behavioral health and traditionally a clinician will see someone with a behavioral health problem in almost every circumstance.

Research shows that outcomes are better if patients have support from someone in Linda’s area [social work] — therapy, counseling, and working with the school — and in the current model, to try and provide that with a patient is problematic. There are problems with finding someone who can actually provide the service, there are problems with the family feeling comfortable going somewhere they’ve never been before with such a sensitive problem, plus patients with behavioral health problems sometimes have a little more trouble getting going. There’s sometimes problems with payment by whomever is paying the mental health provider, and then once they do go, it’s a black hole. The primary care physician doesn’t ever really hear back from whomever saw them, unless the family reports directly, so that’s kind of the traditional approach to mental healthcare treatment and primary care.

Dr. John Bartlett: And this isn’t a small problem, I understand. I mean, I’ve heard some people at the meetings say that 40 to 50 percent of their patients in primary care have depression, anxiety, addiction, so this is really a major part of their work load. Now, they may have other conditions as well.

Dr. Wayne Cannon: Well that’s definitely true.

Dr. John Bartlett: So hopefully the patients in a Medical Home will again have access to evidence-based approaches to getting their addiction, their depression, their anxiety, treated in primary care. It’s clear that not all people who suffer from depression, anxiety, addiction need to go to speciality care. Many of them can be treated quite appropriately, but not necessarily by the primary care physician, him or herself. Right Linda?

Linda Rosenberg: I think the other thing is that special mental health and addiction staff need also to change and to close that loop with the primary care provider. I think that’s an obligation we have that hopefully in this new modernized world we will understand that we cannot just treat an addiction or a mental illness apart from the rest of a person’s condition for the rest of their life. So we have an obligation, if you refer someone to us, to get you that information directly and in a timely fashion.

Dr. John Bartlett: I know that so much of the discussion on health reform focuses on cost. Wayne, you actually have some data from Intermountain about how these kinds of approaches can help save money.

Dr. Wayne Cannon: I think that the scientific literature says that we don’t expect to save a lot of money on the medical side by doing this. However, we found at Intermountain, and we’ve heard at this conference, that many other places have found significant savings in medical expense by implementing a Medical Home for behavioral health problems — and even more than that, there are greater returns for the employer, for the school and for the family; greater quality of life and greater productivity.

Dr. John Bartlett: And also the physician’s as well, if I’m not mistaken.

Dr. Wayne Cannon: The physicians are much happier, plus it saves money.

Dr. John Bartlett: So is this one of those rare examples where you can do well by doing right? Nico?

Nico Prank: Well, I would echo the comments of Wayne. In fact, on the prevention side and health promotion and disease prevention, there is a strong argument for cost savings, not only in the complex of medical care, but also in productivity, and that is strong in emerging literature. But it doesn’t even take that long, either. These are not outcomes that take 10 years to achieve. In fact, if you just look at the decision to do nothing and keep the status quo, within 18 months, there is significant cost savings because you avoid it. When you put these programs in place, very focused on behavioral and lifestyle solutions, such as diet, not smoking, being physically active, not drinking, the savings can come about in a year or two years. From an employer perspective, the productivity side shows up, as well.

Dr. John Bartlett: I do want to follow up on that. Because, [for example] stopping smoking. I mean, I can get [that sort of training] at my local church. What is it about the Medical Home that so intrigues you from a health promotion/prevention point of view?

Nico Prank: I think the key differentiator is the fact that the referral into those lifestyle behavior change programs comes out of the trusted relationship between the physician and the patient. It’s the fact that you had a clinical encounter, that you had face-to-face, one-on-one conversation and heard advice from your clinician, that this is important in the context of your care plan, whatever that may look like, and then you agree to actually take action on that. When the referral then happens, we see very high usage of these services among patients, so I think in the context of the scenario, you just increase the intervention, and therefore, it is so key to actually extend that care team outside of the clinic walls into community-based resources or other venues, like the employer setting.

Dr. John Bartlett: So it’s another example of how you may have an effective intervention, but if it [the care] doesn’t get used, people aren’t going to do well.

Nico Prank: If it doesn’t reach people, or if it researched people at inopportune moments versus them being activated as a result of a teachable moment in which they were truly engaged.

Dr. John Bartlett: Okay, I think at this point what we’d like to do is open it up for questions from the media.

BHC: This is Robin Jay. I’m with Behavioral Health Central. My question is this: Going back to the Medical Home model and the coordination of care management, do we understand how that would be facilitated to make sure that the patient, the primary care doctor and all of the specialists would be kept in the loop of care? Would that be through case managers or would that be upon the different facilities to determine?

Dr. John Bartlett: Wayne, do you want to address that?

Dr. Wayne Cannon: Well, when you have a Medical Home, part of setting that up is answering that question. It will be different in different communities. It will be different in a small, rural community versus a large metropolitan area, but typically on average, behavioral health and the primary care physician would be located in the same office and would be using the same materials to communicate to make records, so there’s a common medical record and an established way of communication, whether it’s by messaging within the medical record or email. And the care manager is another part of the team. There are many different ways to do care management. Ideally they would also communicate through that same method, typically face-to-face and electronic.

Dr. John Bartlett: I think I heard you say yesterday, and I want to follow up on it, you know, there’s no single design for the Medical Home. It has to work on a local level and local can even be down to the individual doctor’s office. I think I heard you say you have like 50 different clinics within Intermountain across the western states, mostly in Utah, and not all of them have the same approach.

Dr. Wayne Cannon: We have small, rural clinics to large, metropolitan clinics and the design has to be modified depending on your resources.

Linda Rosenberg: I would just add because in your question I think you were also asking, is the coordination at the insurance level or is it at the point of service level? I think certainly, one of the guiding principles is that the coordination and the relationships are as close to the side of service as possible. This isn’t something where an anonymous person is managing your care over the phone who may be insuring thousand and thousands of lives, but this is where you have a physician, you go for care and that physician has someone in their office or they coordinate someone to make sure that they get information from any specialist they refer you to, and that they may also refer you to an exercise program, but it is all emanated under that clinician’s office.

Dr. John Bartlett: I agree that should be as local and as low-level as possible, although we do have some interesting experiments going on. Aetna, for example, is running a very successful program. Their case managers are working on a partnership with primary care physicians who don’t necessarily have access to extra resources. The Aetna case managers are helping do exactly the kind of care coordination and communication that Linda was talking about. Nico was sort of leading up to this, but why is this concept gaining so much currency under health reform? What makes it so attractive?

Dr. Nico Prank: I think from both the health promotion and disease prevention perspective, in sort of thinking very broadly on what a medical home represents, I think within the context of health system reform, it has a promise. I think good evidence behind it is that it can actually address cost issues, and so it lowers cost. It makes the care side more affordable, which of course is a major objective. Secondly, it actually enhances the experience of the patient, which is a quite important component as well. And then it adds to the quality of the care provided and from my perspective, that means have more help be generated. It basically tackles three key components of the healthcare system today.

Dr. John Bartlett: Linda, I know you’ve been involved in building these in community mental health centers around here.

Linda Rosenberg: Yes, we have. There’s tremendous interest out there. We’re trying to get a handle on the escalating healthcare cost of this nation and we know one of the things that tends to happen is that perhaps over-utilization of unplanned hospitalization specialty care, tests — very expensive tests. And there is the hope and I think evidence, that if someone has a relationship, a trusted relationship, a primary relationship with a clinician, that reduces the reliance on unnecessary tests. It would bring down hospitalization, and for people with serious mental illness, we believe we can turn those 25 years and begin to reduce that number and really increase longevity. Most cost come either at end of life or because people have chronic diseases with multiple illnesses. You know, 75 percent of our healthcare cost I think are driven by 4 or 5 percent of the population.

Dr. John Bartlett: Wayne can you give me an example or two of patients for whom this has actually worked well, where it’s made a real difference?

Dr. Wayne Cannon: I talked about a couple of different categories of patients. Let’s say I’m seeing a patient who’s having headache or stomach ache or missing school and it seems pretty clear that it’s a behavioral health problem, that the patient may have a genetic predisposition to depression. We think it’s depression, but often families are resistant to that diagnosis.

So I’ll be seeing that family and if I were to say to them, “You know, I really think your child is depressed and we should try some therapy for treatment,” they might be resistant to that diagnosis or they may not be willing to leave the practice, but if I say to them, “I’d like you to see Quincy this next week, so that she can help you deal with these headaches and stomach aches. It must be causing a lot of stress,” she’ll spend an hour with them, but by the time they’re done with her for an hour, they’ll be asking for more.

Another example would be a patient who clearly has a problem, needs some treatment and wants some help. I can refer them to a person in my site, they can get in within a week. They’re going to see someone that’s part of my team. They come to the same office, see the same receptionist, they see me in the hall while they’re there, and the nurse care manager of my office will call them a week after that to follow up from the visit. So for those who are wanting to get better, it’s straightforward. It’s helpful for those who are avoiding or have other difficult resources. It’s helped them.

Dr. John Bartlett: Linda, how about the population that your organizations deal with? Any patients that stand out?

Linda Rosenberg: We have a number of our member organizations that have been designed to bring some primary care capacity into their organization to a partnership with their neighborhood health center, their federally qualified health center. So in one example, it is very common for people with serious mental illnesses, [that] they are the biggest users of cigarettes. In one center, they brought a nurse practitioner in to do some initial screenings, to track people’s weight, body mass, blood pressures, and then that nurse practitioner is able to say, “Hey, there’s a health center down the block and, guess what? Your case manager John will drive you there and you’re going to see my friend Dr. Morrow who is really good, and I’m going to be talking to Dr. Morrow and then you and I can talk together about what the next steps are.”

Dr. John Bartlett: So that trusted relationship?

Linda Rosenberg: Exactly. And before, what used to happen is they would do an assessment, say, “You’re overweight. You should go see a doctor and bring us back some information when you get it.” And of course a large percentage of patients never went, nor did they bring back any information. So it’s a much more active stance. Really it’s taking responsibility, I think, for the people that you’re serving.

Dr. John Bartlett: For the whole person.

Linda Rosenberg: Exactly.

Kyle Graser: John, this is Kyle Graser. Have the panelists or have you at the conference identified or addressed the overall financing challenges that might be involved in trying to promote Medical Homes across the systems?

Dr. John Bartlett: I’ll let each of the panelists address that in turn and then maybe I’ll add a comment or two. Wayne, you deal with this, I’m sure.

Dr. Wayne Cannon: It certainly came up regularly during the conference. I think that what’s coming out of it [is that] there are, at least from what we’ve seen, sustainable models with a lot of improvement without huge changes in finance. If we wait till things change as far as financing, we’re going to be waiting longer than we’d like to. So there are improvements and things that can be incorporated with Medical Home and the behavioral medicine area without waiting for a finance change. It has been discussed.

Dr. John Bartlett: Linda, any thoughts?

Linda Rosenberg: Yes, we’ve had a kind of robust discussion in this area and gone so far as to discuss things like bundled rates and capitation possibilities — again, saying that healthcare professional in a primary care practice, a Medical Home primary care doctor, has to be able to support these kind of relationships with other parts, you know, whether it’s care coordinator or it’s sending someone out to get exercise or diet. That has to be built in, but there will be savings very clearly from not using high end expensive services, and so that needs to be looked at. And we have had some discussion about it. I think it’s the same discussion that’s going on right now in Congress and that the administration is dealing with in terms of trying to take down money from places where we think there may be some overuse, like hospitals trying to introduce health information technology and preventive practices, that in the end will save some money.

Dr. John Bartlett: Nico, how do your services, prevention health promotion, usually get paid for and what would be the challenges bringing them into the patient centered Medical Home?

Dr. Nico Prank: Typically these are not paid for at all. It’s the individual that pays for them, or the employer. And so, I would actually agree with earlier comments that waiting until the payment reform has all been figured out is probably a mistake.

Starting with strong leadership and taking action is probably a good idea. But it then has to be followed with the payment reform that allows you to get to the objectives of the Medical Home, and to do so, I think that eventually the payment reform will need to sort of start to recognize that you need at least part of the overall payment needs to be related to taking on responsibility of the health of the population rather than just paying for the tasks that are being done. So in that context, it becomes possible, it becomes organizationally relevant, [and] it becomes financially relevant to actually start thinking about prevention in a different way. To start optimizing the use of community-based resources or extended services that allow you to get to underlying reasons and drivers for ill health.

You asked earlier about an example. We had an example of a person that was referred to our health coaching program out of the clinic, a diabetic who was in poor control — overweight, tobacco user, physically inactive, lots or risk factors, high blood pressure, and was actually referred for tobacco cessation services. In the context of the health-coaching interaction, we found out that this person really isn’t ready to stop smoking, but was willing to start walking. So over time, I engaged this person in a 10,000-step side program, a pedometer via a website, being able to track working with a health coach. Over time, the person ended up losing 50 pounds after a year and a half, basically had their diabetes under control, and blood pressure medication completely gone. When you think about it in the context of extending the care team services around behavior change, the care plan is a very powerful way to get in some of these underlying drivers.

Dr. John Bartlett: We had a excellent presentation last night by a corporate medical director of an insurance company in San Antonio, Texas. He has basically, with the support of senior management, been building a culture of health within the USA, affecting all their employees, and is now reaching out to the children and dependents of employees. Basically, their healthcare strategy really has been, "Let’s keep people from getting sick because once they get sick, they go to the hospital, and they spend a lot of money. So lets keep them out of a hospital." And he gave some examples last night where their medical costs have been going up 10 percent a year for the last couple of years, and this program has been in place for four or five years. At this point, they only went up one percent, so management is delighted. There’s some interesting, provocative kinds of examples out there.

Media: I’m just kind of curious as to how do you get all these groups of doctors to come together and participate in this? Is there a challenge in doing that or is it pretty easy to get doctors to come together into these Medical Home environments?

Dr. John Bartlett: Well, yeah, I would say that the Carter Center is a great place to convene a meeting like this. I mean, it’s sort of nonpartisan. People come and feel very comfortable here and I guess that emanates from President Carter and his long tradition of conflict resolution and working on those kinds of problems. You know, frankly, the biggest problem is getting people — and I’m speaking only as somebody working at the Carter Center — is getting on their schedule early enough.

What we found is that everybody — and we have representatives from primary care, behavioral care and health promotion prevention — was very interested in coming together to talk about this. I think the discussion has been very collegial and very productive and very energetic, and we expect that some serious action steps and ongoing processes will come out of it.

In terms of how to get physicians to basically agree on something, I think that in my experience, physicians really do want to help people. I think social workers want to help people. I think psychologists want to help people. I think health promotion prevention specialists want to help people. If you approach it from the aspect of how can we do the right thing by the people that we’re serving, here you can usually get some consensus. I mean you might not agree on every little detail, but putting caring at the center of your discussion is a good way to approach this.

Media: I was just wondering if Dr. Cannon gets any resistance from doctors in his own area, or does everyone that he works with back in the pediatric world seem to really come together and want to do this, or are there challenges?

Dr. Wayne Cannon: Well, I work with pediatricians and internists and family physicians. The challenges are inertia and leadership, but I would say as we look at our outcomes and we look at costs, quality, clinician satisfaction and patient satisfaction, the most dramatic improvement is in the satisfaction of the physicians and other people that work with the patient. So it’s not really resistance, it’s just finding the time to do it. It’s something that people are very happy about, but you really have to have a good leader and you have to have enough time to overcome the inertia.

Dr. John Bartlett: Not just for insurance companies, I guess — it works for doctors, too, but particularly for people. So we will be following up on the results of the discussion today and the ongoing work in this area at Mrs. Carter’s 25th annual symposium in November.
 

For more information about The Carter Center, please go to www.CarterCenter.org.

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