The Doctor Is In

The ideas, alone, horrified Group Health family doctor Harry
Shriver when he first heard them: Answer his own phonewithout a nurse
screening calls first? Give patients his e-mail address?

But these changes were part of a new experiment in health
care that is now gaining attention around the nation.

Its not that Shriver considers himself too important for
such mundane tasks. Its just that from the moment he walked into the Factoria
Medical Center clinic every morning until he left, he spent the entire day
going from exam room to exam room without stopping. Typically, he saw up to 24
patients daily, with problems from the simplea case of the fluto the
complexan elderly person with both diabetes and heart disease. When he wasnt
with patients, he was working his way through paperwork. Each day was, quite
simply, grueling, and Shriver began thinking more and more about retirement.

Today, Shriver sees half as many patients in a day and
spends a leisurely 30 minutes with each. That arrangement gives him time to
communicate well with patients, to sleuth through health concerns physical and
emotional. He picks up the phone when his patients call, and he answers their
e-mails. Shrivers even been known to hand out his home number.

Hes never been happier in his 35 years of practiceand he
believes his patients have never been healthier. Emergency room visits are down
for his patients, as well as for those of his fellow physicians at the Factoria
clinic. Patients are following medical orders better and are more successfully
managing chronic conditions. And Shriver has put off thoughts of retirement.
Im having too much fun, he says.

This new approach to health care, known as the medical home
model, is being pioneered by Group Health and Swedish Medical Center here in
Seattle. Simply put, the medical home concept turns the current model of
primary caremostly provided by internists, family practice doctors and
pediatricianson its head.

At present, the vast majority of primary care doctors are
reimbursed per procedure or based on the number of patients they see. That
method means primary care doctors, who already receive some of the lowest
reimbursements of any physicians, work long days and are able to spend only
perhaps seven to 10 minutes on each patient. Often, theyre double booked: two
patients are in separate exam rooms with the same appointment time. Because
doctors arent paid for double booking and theyre already burdened with
paperwork, its difficult for those in primary care to spend much time on the
phone with patients, let alone to answer e-mail.

In the medical home model, doctors make about as much money
as those in the more traditional insurance-based reimbursement model, even
though they see far fewer patients. The savings come because doctors have more
time to deal with patients medical problems, which results in fewer visits to
the hospital or emergency room. And more doctor-patient interactions occur via
phone calls or secure e-mail, cutting down on costly office visits.

The patients
love it, says Alicia Eng, the clinic operations manager for the Group Health
Factoria practice. Eng, who is a registered nurse with both an MBA and a
masters in health administration, helped guide the clinic through the
transition from conventional practice to the medical home model two years ago.

One of the best parts of the new model is how time for
e-mail is built into the doctors day, she notes. Part of what people go to
the emergency room for is because they work during the day, have busy lives and
cant get in to see doctors, she says. Now they can e-mail at a time
convenient to them, and doctors can respond to them. The average phone call is
answered here within 15 seconds, either by a doctor or a nurse. Eighty percent
of that time, we are able to answer [the patients] question.

Janet Nolte, a Group Health nurse who works in the Factoria
clinic, likens the approach to a wheel with spokes. The doctor and patient are
at the center of the wheel, and othersnurses, medical assistants,
pharmacistsare the spokes that support that relationship. The reason you go
into nursing is because you really want to care for patients, says Nolte, who
spends much of her time working with diabetics, both in person and on the
phone, doing everything from checking blood sugar levels to making sure
patients have appropriate footwear to reduce sores.

The medical home model has, according to studies by Group
Health and others, led to better health and greater satisfaction for patients,
and less burnout and more career satisfaction for doctors and nurses. Its
worked so well over the last two years at the Group Health Factoria clinicand
has proved to be no more expensive than traditional carethat the medical
cooperative is rolling out the model to all of its 26 clinics in Washington and
northern Idaho. Group Health believes this approach also will help retain
primary care doctors, a benefit that could be a major savings, since the
organization estimates it costs more than $200,000 to recruit and train a new
physician.

The glue that holds the program together is electronic
medical records, which provides all those on a patients health-care team
instant access to vital information when a patient e-mails, calls or visits.

Im wildly enthusiastic, says long-time Group Health
physician Suzanne Spencer. She says the amount of time she now spends with
patients makes her a better doctor. This is the reason I went into family medicine.
Every single patient has a story. And that patients doctor needs to hear that
story so the best possible care can be provided, says Spencer, who was medical
director of the Factoria clinic when the plan was rolled out.

The Obama administration has included the medical home model
in its initial plans for health care reform. Although the definition of exactly
what constitutes a medical home model varies, most descriptions place
considerable emphasis on education, lifestyle and prevention, such as monitoring
cholesterol levels, diet, exercise, controlling blood pressure and blood sugar,
timely vaccinations, mammograms and other critical services.

The medical home model may also help attract more doctors to
primary care. Medical students who graduate with up to $250,000 in debts are
reluctant to enter a field that offers long hours, little time with patients
and relatively low pay.

One obstacle to the broader implementation of the system is
that only about a fifth of primary care practices have the centralized medical
records required to make it work.

A version of the medical home model opened this spring in
Seattles Ballard neighborhood, where Swedish Medical Center set aside part of
its hospital for the experiment. Doctors there see patients for up to 60
minutes a visit. Swedish officials say they were inspired to pursue the model
in part because several studies of Emergency Department visits in many
different settings indicate anywhere from 30 percent to 50 percent of visits
are non-emergent, primary care treatable or primary care preventable, says
Dr. Jay Fathi, medical director of Primary Care and Community Health at
Swedish.

Swedish wants the clinic to reflect the real world, so the
clinic is taking patients with Medicare, commercial insurance, Medicaid and
even some with no insurance. Commercial insurers pay a monthly fee for each
patient instead of for each visit. The patients themselves pay an extra $45 a
month for unlimited access to primary care. Swedish believes the model should
pay for itself by finding and treating problems early.

Swedishs Ballard clinic has two family physicians, six
residents, a clinic coordinator and a nurse, as well as medical assistants on
staff. Dr. Carol Cordy, Swedishs medical director for the site and the residency
program, says she believes the medical home model is the wave of the future and
that studies will eventually back her assertion. One of the things well need
to able to do efficiently is [make sure] that all your kids are immunized, make
sure that women have paps and mammograms, Cordy says. Because of this
different model of care, diabetics will have better control of their care, the
depressed will be less depressed.

Her first week in the clinic was a revelation, Cordy adds,
with appointments of up to an hour with patients, who were able to give her
complete health histories and list all of their concerns, giving her a chance
to really educate them about medical issues. Were pretty optimistic well be
able to say this is a cost-effective way to take care of patients. Some people
have said were just handholding, but isnt that what were supposed to
do?