While the Affordable Care Act continues to dominate health and wellness headlines in Alaska, a concept described as a quiet health care revolution is slowly building ground in the Last Frontier.
The concept -- called the patient-centered medical home model -- has been around for nearly 20 years. PCMH is finally making its way to Alaska, bringing along the potential to drastically shift how health care is run in the state.
The goal of PCMH is to treat a patient as a whole person, not just address a given affliction. It seeks to combine both mind and body and acknowledge that behavioral health issues can contribute to illness. PCMH relies on team-based care to provide the best possible treatment at the lowest cost.
“It says we don’t want to compartmentalize you,” said David D’Amato, senior director of health policy with the Alaska Primary Care Association. A nonprofit member service organization comprised of 28 community health centers in Alaska, APCA works closely with the state and Alaska Mental Health Trust Authority in examining health care policy.
D’Amato called the health care model a “quiet health care revolution” that has the potential to make Alaskans healthier and reduce costs to facilities and, in turn, to patients. In the coming weeks, APCA will begin accepting applications from health care providers hoping to further the goals of that so-called quiet revolution.
“What’s hard about explaining it is it seems so obvious,” Heidi Baines, medical director at Anchorage Neighborhood Health Center, said. ANHC is one of a handful facilities in the state that are recognized PCMH facilities.
At ANHC, patients are assigned to a “pod,” one of the facility’s intake centers, where they sign in to appointments. Patients work with one primary physician and a team of care coordinators. The goal is for the patient and team to form a relationship over time. That in turn allows for the building of trust and the better management of care.
Referrals are also integral to PCMH’s goals. “A big piece is following through,” Baines said.
Specialist referrals are done in-house when possible. At ANHC, patients can get blood work done, see a counselor, or have X-rays taken, among other services. When referrals are made to providers outside ANHC’s walls, that specialist sends a report back to the patient’s primary care physician. That helps the primary care provider make the most informed decisions about patient care. Having all that information in one place seems obvious, but it’s not common practice.
Since the implementation of PCMH in the U.S., studies have been indicating that the approach improves patient care and reduces cost. A 2013 study found that at the Southcentral Foundation, an Alaska Native-owned nonprofit serving nearly 60,000 Alaska Native and American Indian people, under the PCMH model, emergency care use dropped while patients observed better access to primary care services and better relationships with their doctors and care team.
Department of Health and Social Services Commissioner William Streur has been a proponent of PCMH in the state for years. “It’s a no-brainer,” he said.
While the model has been around since the late 1990s, Alaska has lagged in adopting it. “We’re behind in most health care” practices, Streur said.
The first state funding for a PCMH pilot project was secured in 2011, when the Legislature approved a capital grant to support transition to the PCMH model for three community health centers in Alaska: Alaska Island Community Services in Wrangell, Sunshine Health Clinic in Talkeetna, and Bethel Family Clinic.
The state continues to work toward implementing this model. In coming weeks, APCA will be accepting grant applications for providers hoping to work toward PCMH goals. Roughly $1 million will be available.
It will be “one of Alaska’s first million-dollar efforts to reform health care,” D’Amato said.
The Department of Health and Social Services is also looking at how the payment structure will work -- a question still up in the air. The state is also developing an online electronic records system that will link providers, which will allow for the easy transfer of medical records, Streur said.
But while PCMH is an intuitive concept that appears to have good results, it is still a challenge to implement on the practical level.
Tracking results, cost reductions
To earn and maintain PCMH accreditation, Anchorage Neighborhood Health Center is tasked with tracking a wide range of statistics, including referrals, the number of visits that people actually attend, and no-shows. If patients don’t make their appointments, ANHC follows up and tries to figure out why.
Physicians track success in a wide range of areas and must verify that they are making progress with referrals and certain goals set each year. That’s a lot of pressure on the doctor.
“It’s scary to providers, I think, to be measured,” Baines said.
Yet small procedural changes allow for providers to reach these goals. For instance, ANHC will offer Pap smears to female patients during their visits even if that isn't the reason a visit was booked. ANHC has significantly bumped up the number of its female patients receiving Pap smears on schedule using this simple tactic.
The comprehensive coverage, follow-through and holistic approach to care end up saving the system money.
Reduction in costs and payment reform are other main goals of PCMH. In the US, roughly 30 percent in annual health care spending is estimated to be unnecessary -- around $700 billion of the $2.5 trillion the nation spends every year on health care.
Through better tracking systems and team-based care, PCMH providers ensure that tests and procedures are not accidentally repeated. Since the team knows what the patient needs, procedures are more likely to be relevant to the patient’s care. And as illustrated in the Southcentral Foundation study, PCMH results in a decrease in one of the most costly aspects of medical care in the US: emergency room visits.
Josh Applebee, deputy director at the Department of Health and Social Services, noted that Alaska has some of the highest health care costs in the nation, and by extension, the world. Yet the state’s health care outcomes are not great.
“Everybody benefits from a more efficient health care system,” he said.
Questions about payment
The way payment will work under PCMH is a plan that's still being formulated. The conventional medical payment system, called fee-for-service, is based on treating diseases as they arise. Providers are paid for each individual service they provide: Order an X-ray, and charge for that service. But with PCMH, providers seek to treat the whole person and prevent illness in the first place. A system that's no longer disease-based raises questions about how charges will be formulated.
Those payment questions are what’s keeping the Tanana Valley Clinic in Fairbanks from seeking PCMH accreditation.
“We could be accredited today,” CEO James Shill said. Like ANHC, Tanana Valley Clinic patients have one primary care physician, and many specialist referrals can be done in-house. “We call Tanana Valley Clinic ‘your medical home’ -- that’s what we are.” The problem, he said, is that there’s no payment model in place that would allow Tanana Valley Clinic to become accredited and stay in the black.
The state is reviewing options as to how payments will work. The most likely candidate is something called the “per-member per-month” model.
Under per-member per-month, providers receive a specific amount for each patient they serve every month. They can then use that money however they see fit to best run their clinics.
This is a big shift from the fee-for-service model most providers currently use. Per-member per-month necessitates efficiency in provider practices, cutting back on unnecessary services estimated to account for so much wasted health care spending.
It also allows for some flexibility for providers. At Anchorage Neighborhood Health Center, it allows them to pay for care coordinator positions, crucial to their team-based system, for which there is no billing code in the current fee-for-service model.
But those agreements will need to be formed between the provider and payer. In Alaska, Premera Blue Cross is the largest insurance provider. Premera is working to move toward that kind of payment system, but Eric Earling, director of corporate communications for Premera, acknowledged that it “does take a lot of discussions” between the provider and insurance company.
Given that the payment system is so different, the company is trying to find “a way to make it happen over time,” Earling said. The company has worked with providers in Washington state to use a system called Global Outcomes Contracting -- an essential stepping stone between the current fee-for-service model and the desired per-member per-month model. With Global Outcomes, providers receive monetary incentives for providing quality, evidence-based care.
Trial runs have shown the system works well with smaller providers. It’s more challenging to implement the payment system across larger carriers that have multiple facilities, Earling said. However, he added, “it’s really more of a question of when, and not if,” the payment system, and health care system at large, will shift to the PCMH care. And along with that shift will come the potential for healthier Alaskans.