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The Honolulu Advertiser
Posted on: Tuesday, June 1, 2010

Hawaii health plans back 'game-changing' reform

BY Greg Wiles
Advertiser Staff Writer

The Hawaii Medical Service Association and health care providers such as Hawaii Pacific Health want to change the way you care for yourself and receive treatment.

It involves a surprisingly unsophisticated concept revolving around you and your doctor.

They want you to spend more time thinking and talking about your health with your physician, who also will be a team coordinator of sorts when it comes to you getting specialized and other care.

So get ready for something with the unlikely name of "Patient Centered Medical Home," a concept that is gaining advocates nationally as a way to improve patient health while tamping down rising health care costs.

"It's game changing in what we're talking about now. What we've done is piece work and paid for piece work," said Chuck Sted, president and chief executive officer of Hawaii Pacific Health, operator of Kapiolani Medical Center, Straub Clinic and two other hospitals.

Now "the focus is on keeping people healthier."

Such programs are already being hailed nationally as improving health and lowering costs at the Geisinger Health System in rural Pennsylvania. Kaiser Permanente, the state's No. 2 health insurer and health provider, also is seen as achieving good results with its focus.

"It is likely to be the best opportunity for aligning physicians and patient frustration, demonstrated models for improving care, and private and public payment systems to produce the most profound transformation of the health care system in anyone's memory," according to a report on Patient Centered Medical Home done for the American Academy of Family Physicians.


Some of the impetus for the change comes from spiraling health care costs and doctors, hospitals and insurers looking for ways to keep people healthier.

Increasing use of services and other costs has led to medical care rising at 1.3 times the rate of inflation in the state during a five-year period ending in 2008, according to figures produced by the Hawaii Health Information Corp.

That also can be seen in rate increases by HMSA, the state's largest health care insurer. When a 7.8 percent rate hike goes into effect on July 1, premiums for small businesses will have more than doubled in the past decade.

In economic parlance, that's known as being unsustainable.

"We all recognize that the cost of health care continues to be on a path that does not have a future," said Steve Van Ribbink, HMSA executive vice president.

"We're moving away from a system that's based on quantity to one that's based on quality."

Much of the current problem is said to stem from a system that favors payments for services rendered instead of a focus on a quality outcome for a patient. That, combined with lower reimbursements for general practitioners, has many primary care physicians running from one examination room to another throughout the day.

"We have a reimbursement structure that reimburses physicians, hospitals and doctors based on how many times patients visit, instead of a system that encourages keeping them healthy and out of doctors' offices," said Dr. Jerris Hedges, dean of the John A. Burns School of Medicine.

Hedges said the Patient Centered Medical Home seeks to correct that by going back to the days when people might have a family doctor they would see for decades and who could coordinate care. That's compared with today's system, which can be fragmented and specialized.


The medical home concept has some of its roots in Hawai'i, where the notion of having centralized medical records and a partnership between parents and a primary pediatrician was put into practice in the late 1970s by Honolulu pediatrician Calvin Sia.

"The concept of having a Medical Home is actually something that Calvin Sia popularized with the American Academy of Pediatrics," Hedges said.

He said the concept has since been broadened a bit and now includes the use of electronic medical records. As such, a patient's care team can have ready access to records, lab tests and X-rays instead of ordering new ones.

The records, when coupled with the coming establishment of health information exchanges, also will make health care delivery more efficient when patients are rushed to emergency rooms or are traveling.

Hawaii Pacific Health's $55 million electronic medical records system has come into play as the state's largest health care provider embarks on its own Patient Centered Medical Home program, or PCMH.

HMSA also has worked to get such systems adopted by doctors in recent years.

Hawaii Pacific Health's system can be accessed by patients, something that plays a role in doctors engaging people in their own health care and establishing a closer relationship between patients and physicians.

For example, diabetics can track their hemoglobin A1C test results online to watch their progress.

Software also is in place to alert doctors to test results outside the normal range. Such technology, along with changes that allow other health practitioners to perform functions for doctors, will free up more time for physicians to counsel patients or monitor their patients.


In other aspects of PCMH, a nutritionist may work with overweight patients, or health educators may give guidance to patients, working with physicians. All of the work is geared toward having a healthier patient population that doesn't need as much hospitalization and visits to emergency rooms.

There, too, are gains expected as people with chronic conditions receive more attention and care to help them overcome health problems. As Hilton Raethel, HMSA senior vice president notes, PCMH can help with cutting down on overuse of health care while identifying underuse and misuse.

"It puts the physician-patient relationship at the center of the care delivery system," Raethel said.

That goes hand-in-hand with another major change proposed by HMSA under PCMH: aligning insurer reimbursements with delivery of quality health care that is evidence based, reliable and cost effective.

"If we want a different set of outcomes, if we want to improve quality, we have to change the incentive structure," Raethel said.


Currently about 2 percent of HMSA's reimbursements to hospitals are based on quality outcomes. Over the next three years it wants to boost that to 15 percent, with the remaining 85 percent based in fee-for-service.

HMSA, like Hawaii Pacific Health, has been going out to the community and physicians to detail the shift. HMSA said it is rolling the program out statewide and has been meeting with hospitals, independent physicians groups and others to discuss the system.

Sted said many health care leaders think PCMH should be enacted as a way to improve care and stop cost increases.

"A lot of people in government that weigh in on policy think this is the way to go, too," he said.

HMSA believes the message is resonating with physicians and others.

"PCMH is the necessary foundation to move toward, ultimately, a sustainable health care system," Van Ribbink said. "We really want to engage our members in their health care."

Still, it remains to be seen if PCMH can scale and whether all patients will embrace taking more responsibility for their health. So, too, are there questions of how the system will work when Hawai'i is grappling with a shortage of primary care physicians. A recent medical school study found Hawai'i was short more than 500 physicians, with many of these being family practitioners who are the heart of the PCMH system.

"It's going to be tough, but I'm glad Hawaii Pacific Health and other big health systems are moving in this direction," said Beth Giesting, executive director of the Hawaii Primary Care Association.

"It's definitely the right idea."