Let me tear off my provincial Massachusetts blinders for a moment to say: We’re far from the only national laboratory for health reform. And something deeply interesting is going on in that fair city on the left-coast Bay, San Francisco.

So interesting, in fact, that the program, “Healthy San Francisco,” is a finalist for a major award from Harvard Kennedy School, the Innovations in American Government Award given out by the Ash Center for Democratic Governance and Innovation. (Winner to be announced early next year.) The 16-minute presentation above to the award judges provides a succinct overview, but here’s my one-liner: Unlike Massachusetts, San Francisco didn’t try to get everybody insured; it just aims to provide health care to the uninsured people who need it — not just in emergencies, but long-term, primary and specialist care.

I spoke with Berkeley health economist Richard M. Scheffler, who evaluated “Healthy San Francisco” for the innovation awards, about how the program works, and it certainly has its limits — including the city limits: It doesn’t extend beyond them. But what struck me is that, beginning in 2007, the program aimed to address health care delivery issues that we in Massachusetts are only getting to in a sweeping way now, such as the question of whether everyone should have to have a primary-care “medical  home.”

It also struck me that, though employers and taxpayers foot the bill, Healthy San Francisco addresses the problem of the uninsured by focusing mainly on them, and arguably affects the broad population less than in our health-insurance-for-all state. Readers, what do you think? Would something like Healthy San Francisco work elsewhere, beyond the bounds of that famously liberal city? Would you want it to?

My chat with Richard Scheffler, lightly edited:

So what’s so cool about ‘Healthy San Francisco” that it merited being an award finalist? It strikes me as such a dramatically different model from Massachusetts, much more narrowly targeted…?

What’s cool about it is that, as you mention in your question, it’s a very different approach than Massachusetts — or even the Obama plan. The Massachusetts model is fundamentally based on trying to help people obtain health insurance. But it does nothing about the access problem: the plight of safety net hospitals, lack of primary care doctors, overuse of emergency rooms, uncoordinated care. So San Francisco, to compare it to an insurance approach, it’s what you’d call an ‘access approach,’ It’s actually to provide access to health care.

It does have limits: You have to be a resident of San Francisco; you have to have an address and show you live in the city, and the plan covers you only when you’re in San Francisco. So if you have to take the BART train — which is our MBTA train — to visit me in Berkeley, you wouldn’t be covered. So it does have its limitations, but it is basically an access program, which is different from an insurance program.

Different — better??

I wouldn’t say better. It’s a very different approach. Better is a tough term.

Approaches to providing quality and affordable health care for people can vary in different parts of the country, and I think we need a bit of both.

What San Francisco does to provide care is: It has people in one of three options. If you’re working, the employer is mandated to spend a certain amount of money on your health care for you. That’s a mandate. The mandate is on the employer, not the individual as it would be in Massachusetts.

And so that employer can either buy you insurance, or set up what we call a Flexible Spending Account — put some money in a bank account you can use — or enroll you in the Healthy San Francisco program, which is a publicly run program set up with a series of what we call ‘medical homes’ — a place where you can get all your care in one particular spot. It’s usually some kind of community clinic.

And then to pay for that, if you’re an employer, there is some money added to the wage bill: It’s about $2, give or take, for every hour an employee works more than eight hours, that needs to be paid.

That’s where that money comes from. And then the state puts in some money on a waiver to help out. And the city puts some of its own public money into it. So there are contributions from different places, that’s basically how it’s financed.

How you get your care depends on which one of these plans your employer happens to pick for you to satisfy what we call a spending mandate — the amount that the employer has to spend on your health care. It’s a flexible model, it’s not one-size-fits-all. Some employees encourage their employers to buy insurance for them; some like these spending accounts; and some like the public system of clinics which is set up throughout the city.

This San Francisco program that started back in 2007 seems to address access issues that Massachusetts seems to only be getting to now…

Massachusetts, of course, is a system for an entire state and this is just one city. So it’s hard to make those comparisons.

I would have you think about it this way: The number of people we have uninsured in California, which is about 16-17% of the population — that’s the entire population of Massachusetts. It’s a different scale. The Massachusetts issue is very different from the California issue.

But back to Massachusetts, I think the state has done a reasonable job on coverage — it has a high coverage rate, probably in the high 90s, and I think that’s a good thing, and they set out to do that. Now they’re finding the problem is the cost of delivering the services. They got people insured and then there was no sort of fix for the delivery system.

In the case of Healthy San Francisco, there are give-or-take 50-60,000 people enrolled in it in total. And the positive thing is that all the parties — the providers, the hospitals, the unions, the employees, the employers — they’re all generally happy with the program. Of course, people complain here and there, but generally, no one’s talking about trying to do away with this program. It’s pretty set in the San Francisco culture.

When I talked to the labor representatives and people in the mayor’s office, nobody had any thoughts about, ‘We have to get rid of this program.’ They all talked about trying to improve it.

What San Francisco did that Massachusetts didn’t do is using ‘medical homes’ and primary care clinics and electronic medical records, and trying to reach out to patients to do prevention and work with them and coordinate their care. That, I think, is a big advantage of what happened in San Francisco and didn’t happen in Massachusetts.

But remember, it’s not technically an insurance program, because if you leave the city, you’re not covered. It’s an access program for residents when you’re in the city. It’s a very different approach.

What would you say is its biggest problem?

The greatest problem I find is that when you talk to people, they’re so used to the influence that Massachusetts has had being a groundbreaking program — and then the follow-up of the Obama plan, which does take a lot of its elements from Massachusetts — that they think Healthy San Francisco is a plan like that. Which it isn’t. So they have really a marketing or labeling problem.

People don’t understand it. And I have found even some of the providers in San Francisco who take care of patients, doctors I’ve spoken to and hospital administrators, still think people coming in there have insurance, but they don’t.  So the problem is that people don’t understand the program and how it actually works.

And there’s always the issue of who’s going to pay a bigger or smaller share. As I pointed out, the financing comes from different pots of money. Whenever there’s money involved, people fight over it. But the good thing about money — that you can’t do when you’re fighting about principles — is that you can alway divide it up somewhere in the middle.

Why do you think there’s not more of a ‘Healthy SF’ element in the Obama health overhaul?

Actually there is, not in financing but in delivery — medical homes and primary care and prevention. And once the Obama insurance part fully clicks in, I think more communities will start to look at the prevention and community part,  and San Francisco will then be a model of what’s possible, at least in an urban environment.

Is it unique at this point? 

It’s quite unique — that’s why it’s up for an Innovation Award at the Kennedy school. It’s the only health care innovation among the finalists, so I think that speaks for itself. There’s a community program in Maryland called Healthy Howard that’s a knock-off, and I think in California now there are a number of counties that are considering doing this as well. But quite frankly, it hasn’t spread like wildfire.

Why not? 

I think it just requires leadership at the governmental level. And it requires people to kind of get along. The politics of our day, unfortunately, is not for people to work together, particularly on the political front.

Was the culture of San Francisco key? I certainly think of it as a city that is kinder to the homeless, and to the poor in general, than just about anywhere else. 

I don’t think it’s any surprise to anybody that San Francisco is socially more progressive, and it’s definitely more of a liberal city than others in the US. But I don’t think it’s really about being more liberal. I met with a lot of the people who put the program together, and some credit needs to be given to leadership.

Gavin Newsom was mayor at the time — he’s now lieutenant governor, and looking for a higher office after that, no doubt — and he was able to bring all these parties to the table and, I believe in a three or four month period, with a series of meetings, get them to sign on to this. I think it takes some creative leadership from the mayor’s office, but it wasn’t the mayor alone, to be sure. It was people in leadership positions in San Francisco who understood that it was actually good for everybody for San Francisco to be considered a healthy city.

Editorial post-script: This is all by no means to imply that our Massachusetts reform is chopped liver. The Massachusetts agency that helps people get health insurance, the “Connector,” won an Ash Center Innovation Award in 2009.

1. She used to take her asthmatic son, Ycaro, to the emergency room every time he needed a refill for his inhaler. She didn’t know she could simply call the doctor for a prescription and pick it up at the pharmacy.

2. She was confused and anxious when Ycaro, 11, was diagnosed with childhood depression. “Here, it’s normal for kids to be in therapy; in Brazil it’s not normal, ” Fernanda said. So, she cancelled or skipped 10 pediatric therapy appointments.

Enter Erica Guimaraes, a community health worker, and part of an ambitious program here to provide better, more effective care to poor, chronically ill patients — some who cost more than $200,000 a year to treat.

Since October, Erica has visited the Pereira’s home at least twice a month to help them deal with their medical problems, mental health struggles, cultural challenges, and anything else that comes up. On a recent visit to the family’s tidy brick apartment above a pizza place in Medford, Erica taught Ycaro how to properly use his inhaler. She explained to his mom, once again, the difference between Flovent and Albuterol. And she set up in-home therapy sessions for Ycaro. The boy has not been to the ER since Erica started visiting. “This winter, with Erica, it’s better,” Fernanda says.

Low-Tech Lessons in a High-Tech City

Here in this wealthy medical mecca of high-tech hospitals, Erica is part of an experiment to use low-tech lessons learned in the poorest of countries, Haiti. As Massachusetts, and the nation, begin to revamp a broken health care system, the need for these health workers, who fill a critical gap by supporting families in their homes, is clearer than ever before, says Partners In Health co-founder Paul Farmer, the doctor famed for developing a cadre of such workers in Haiti. “There has been more discussion about the need for innovation in this arena this year than ever before,” he said. We are finally acknowledging that “it is very expensive to give bad medical care to poor people in a rich country.”

While Fernanda’s daughter Katherine, 4, watches a Dora video, Erica and Fernanda chat in Portuguese, intimately, like sisters (they are from the same state in central Brazil) about the challenges of dealing with the new 4-month-old baby. Erica helps fill out a form so the infant can get health insurance. She’s frequently on the phone with MassHealth — Pereira has missed some key deadlines which led to the children getting dropped off insurance. Erica handles that, along with the problems of 21 other children who are part of her caseload.

Henrique Oliveira, another community health worker, recently spent four hours working with one of his patients — a morbidly obese, depressed mother of three children still in diapers, with a recently laid-off husband — on how to clean her truly filthy apartment. “Sometimes even I get overwhelmed,” Henrique said. “But I just take it one step at a time.”

Navigating a Complex System

Community health workers fill a crucial gap in the health care system: they are part nagging mom, part medical fixer, part translator and guide through the daunting insurance and social service bureaucracies that can overwhelm even the most savvy health care consumer. These workers, carefully screened and trained, patch together the kind of care that doctors and other medical providers can’t possibly offer — and were never really trained to deliver. They take on the harsh nitty-gritty of their economically-strapped patients’ lives: the transportation and school and housing problems, the bad food and ubiquity of drugs, the social and employment obstacles that can devastate families. These problems, left untreated, can exacerbate illness, and what was once preventable becomes chronic and eventually acute. Hospitalizations and ER visits accumulate and health care costs continue to rise.

Community health workers are supposed to help break that cycle. “It’s not necessarily about the specific tasks they do, it’s about the relationships, the constant accompaniment, the overall promotion of wellness,” says Dr. Heidi Behforouz, an internist and associate physician in the Brigham and Women’s Hospital Division of Global Health Equity, who serves as medical director for the new Network Health Alliance program. “It’s not reimbursable, but it’s powerful.”

The new program deploys community health workers, who earn from $38-$40K a year, as foot soldiers in a “care management” team that includes nurse practitioners, social workers, mental health and behavioral specialists and others. The goal is to bring the most complex, disengaged (and expensive) patients back into the primary care fold and teach them how to better take care of themselves and their families.

The project is modeled in part on PACT — Providing Access to Care and Treatment — a program Behforouz, also an associate professor at Harvard Medical School, launched at Partners In Health, which is better known for its groundbreaking medical work in countries like Haiti and Rwanda. Indeed, it is PIH’s development of a corps of community health workers, or accompagnateurs, in Haiti, and then in Peru and across Africa that became a model for its U.S. efforts. (Today, PIH trains and employs over 2,000 Haitians as accompagnateurs, and these health workers were critical during last year’s devastating earthquake and subsequent cholera outbreak).

The Holy Grail: Better Care, Lower Cost

PIH’s local PACT program, launched in the mid 1990s in Roxbury, hires community health workers from the neighborhood to help supplement the care and treatment of the most marginalized people in the city: late-stage AIDS patients, many who are mentally ill, traumatized, using drugs and without secure housing.

An analysis found that after patients were on PACT for two years, the program realized a net savings of more than 15 percent. Other PACT-like projects have been launched, in New York City for patients with AIDS, for instance; similar projects use the same basic design but target other diseases that disproportionally impact the poor, like diabetes. This type of approach — primary care-focused with readily accessible backup treatment and social support brought right to the patient’s doorstep — appears to deliver better quality care at lower cost, the Holy Grail of the entire health system.

“This is a transformational moment for primary health care in the United States,” says Paul Farmer. “In the shadow of Harvard’s massive teaching hospitals, Heidi’s signal contribution has been training community health workers to deliver care for chronic diseases in people’s homes and neighborhoods. Whether in Rwanda or Roxbury, community-based care is the highest standard of care for chronic disease; community health workers make care more effective and efficient even as they make it more patient-centered and humane.”

The new PACT-like program, called Network Health Alliance, is a partnership between Cambridge Health Alliance, its managed-care partner, Network Health, and Commonwealth Care Alliance, which hired the Iranian-born, Harvard-educated Behforouz. (Commonwealth Care runs a comparable program for chronically ill seniors, and was able to cut their hospitalization rate in half).

Launched last year, Network Health Alliance now serves 2900 poor, chronically ill patients, including 700 children.

One Patient: $50K Per Month

Many of these patients have complex mental and behavioral problems and all have at least two chronic medical conditions. Dr. Pano Yeracaris, vice president and and Chief Medical Officer at Network Health says most of these patients cost between $500 and $15,000 a month to care for — the most expensive patient is over $50,000 a month. The patients are separated into groups, including “high touch,” who need lots of intervention from a variety of specialists, including visits from the one of the program’s 10 health workers, to “medium touch” patients who are carefully monitored, with frequent check-ins and round the clock phone support available from a nurse practitioner.

There is currently no data available on whether the program is saving money. The up-front investment was “a few million” (the directors wouldn’t tell me precisely how much). Behforouz says the program may actually lose money in the first year, but in three or four, costs might began to decrease by 2-3 percent. (Initially, cost-saving estimates were higher. But because some of the patients involved cost less than expected, and because many of them “churn” off the Network Health plan, which they must be on to be eligible, the projected cost savings is now more conservative). So, the question remains whether this type of staff-intensive program — however beneficial it is for patients and providers — will actually win longer-term funding and support in the current economic climate.

For now, Behforouz says, the program is focused on prevention: for instance, many patients are being admitted to the hospital for poorly controlled diabetes — admissions which likely would have been unnecessary with proper oversight. (It’s the same story with a range of illnesses: asthma, pulmonary disease, gastrointestinal problems, alcohol-related disorders, recurrent cellulitis, congestive heart failure). “We’re interested in seeing health care utilization patterns improve, hospitalizations and ER visits go down, improved engagement with primary care and behavioral services, improved health quality and improved self-management skills,” Behforouz says.

It’s not going to be easy.

A Family Out of Control

Enter the Revere apartment of Jessica (you’ll see in a minute why I’m not using her last name) and you’re immediately hit with an overwhelming sense of chaos: the place is trashed, the diapered children — ages 1, 2 and 3 — are dirty, the baby has an odd rash on his body; old, dried food cakes the trays of the kids’ high chairs. The most striking piece of furniture is a huge, industrial garbage can sitting right in the middle of the kitchen. Jessica is morbidly obese, and she seems to have given up on controlling her frenetic kids, none fully clothed in the middle of the day.

The oldest girl, Brianna, is overly solicitous, but sweet — she immediately jumps on me with none of the normal self-protective wariness a child might demonstrate on encountering a total stranger. Despite repeated orders, Brianna doesn’t really get the concept of an “inside voice” and already has outsized problems: developmental delays and difficulty managing her behavior, she screams, sometimes bangs her head against the wall and recently came home from daycare with bite marks on her arm. (Jessica immediately pulled all the kids out of the day care). Despite Jessica’s certainty that something isn’t right with Brianna, she says the pediatrician won’t offer a definitive diagnosis — she doesn’t want the child “stigmatized” at such a young age.

Jessica’s husband recently lost his job at the Dollar Store, so he’s home cooking noodles for the kids. About six months ago, he was screaming at his daughter so loudly that a neighbor called 911. Now the state Department of Children and Families is involved, though they haven’t taken any action yet.

And Jessica? Here’s is a partial list of her health problems: schizoaffective disorder, asthma, generalized anxiety disorder, PTSD, insomnia, anemia, depressive disorder. She doesn’t have a car, so getting to appointments with her children in tow is a major ordeal. Recently, she managed to get them on a city bus, but the driver kicked them off because the children were too wild.

One agency recommended parenting classes.

I asked Henrique Oliveira, the community health worker, how he can even begin to help this family with so many needs. “I have to work step by step,” he says, offering a list of specific tasks. “I can’t do everything at once.” Three months ago, Henrique said, Jessica’s husband mentioned having another baby. “I was speechless,” Henrique said. “I told them, ‘You guys really need to think about this first. You are dealing with three kids that you are having trouble managing and you’re thinking about having another one? That’s not a great idea.’” He recently scheduled a gynecologist appointment for Jessica to get birth control.

Health workers are supposed to “empower” patients to help themselves, but still, Henrique admits, he recently “picked up a sponge” in an attempt to teach Jessica the basics of scouring a bathroom. “She has no idea how to organize and clean the house,” he said. “I tried to show her, not do it for her.”

Frankly, it’s hard not to feel hopeless about the prospects for this family. I left the apartment wondering if any system in the world could take these fragile, disconnected people, all of them, and somehow, make them better.

But a few weeks later, I got email from Henrique telling me that Jessica and her family, seemingly in such a deep and inescapable rut, are doing a little better.

Here, slightly edited, is what Henrique wrote:

The Family is doing ok! They finally, last week, were able to find a Day Care. All 3 kids are going to day care now.

Jessica is looking for a job now (just gave to her the information about a Job Fair in Somerville).
She is seeing a new psychiatrist and just started with new meds (feeling much better).
She is also scheduling an appointment with an audiologist.
I will see her this week to start teaching her how to clean the house.
I stopped by last week with a Behavior Health NP to do a new assessment.
Jessica is scheduling an appointment to do a genetic test with Brianna, to get a better diagnoses about her.

I was able to engage P. (husband) with his Care Manager and now he is going to schedule the appointments. The Care Manager will engage him with PCP/Psychiatry/ Job search.

We all getting together next week for a meeting.

Henrique

(A 2011 Favorite)

At 82, Phyllis is complex. Medically, that is. Widowed young and veteran of 35 years in the financial services industry, she comes across as a resilient spirit, all backbone and humor and gratitude for small favors. But there’s no denying she’s up against a lot: diabetes, asthma, chronic lung disease, a blood pressure problem that leaves her prone to sudden blackouts. At one point, she was on 20 different medications.

Luckily, Phyllis has a secret weapon these days: Wendy Atamian. A nurse with 35 years of experience, Wendy is Phyllis’s “nurse care manager,” which means that she stays on top of Phyllis’s health: She helps coordinate her doctors’ visits and medications; sets up home-based services after hospital stays; advises her if she’s in pain or can’t sleep. Wendy even suggested a simulator test to help determine whether Phyllis should still be driving.

“Wendy is always there when I need her,” Phyllis said. Together with Phyllis’s primary care physician, Dr. Michael Bierer, “I think they’ve saved me many trips to the emergency room and urgent care” — “which is a blessing.”

It’s not just a blessing for Phyllis — it’s a money-saver for the health care system. Older patients with multiple chronic diseases are the biggest consumers of health care; some 15 percent of Medicare patients make up over 75 percent of health care spending. Cutting the costs of their care is a must if the relentlessly rising health cost curve is ever to be bent — the goal of the next phase of Massachusetts reform.

Multiply Phyllis Minsky by 3,200. That’s the number of patients in the five-year-old pilot project that she’s part of, the Mass General Care Management Program. Begun at Mass General, the care management program has now expanded to Brigham & Women’s Hospital and the North Shore Medical Center, for a six-year total of more than 8,000 patients.

And that may be only the beginning.

More to come

When Gov. Patrick presented his plan for the next phase of health care reform last month at a crowded Chamber of Commerce breakfast, he picked out the Mass. General project as a model of where he wants the state’s health care to go.

Asked about estimates that 5% of the population rack up 50% of health care costs, Patrick sent a shout-out to Mass. General — “Who’s here from MGH? Own up to it!” — then described the care management program:

“They focus on their sickest patients, they intensively manage their needs…and they have shown that by managing that care, they actually reduce the cost of that care for the sickest patients.” he said. “The problem is that in the system we have right now, they don’t get paid for any of that. What we pay for is more care.”

The care management program, he said, “is one of those brilliant moments, it seems to me, where better care — a whole-person approach –is actually cheaper! So what we want as a patient actually serves the system well in terms of containing costs.”

Determining the exact amount the care management pilot saves is tricky, but an independent analysis pegs the savings at 7 percent. That’s more impressive when you consider that the savings came despite hiring 15 nurse care managers, and despite lengthened lives — and therefore more care — for some patients. Mortality is 4 percent lower for the pilot’s patients than in a comparison group. (Reports and other data on the pilot can be found here on its Website.)

It’s even more impressive when you do the national math: A publication by the National Academy of Sciences estimates that close to a billion dollars could be saved annually.

Medicare pays the Mass. General Physicians‘ Organization a monthly sum of money for managing each patient, and for every dollar Medicare invests, it saves $2.65.

The physicians‘ group took the gamble that it could do the job within the Medicare budget — and during the startup phase, costs increased as the care managers gained traction, but that changed within several months, and the project recently won an extension of Medicare’s backing through 2012.

Deval Patrick is not the pilot’s only fan. In the legislature, Jeff Sanchez, the chair of the House’s committee on public health, has just proposed a bill that would push the program a step further. Right now, the pilot handles only elderly, medically complex Medicare patients. The bill proposes a similar pilot project for complex, chronically ill patients in MassHealth, the public insurance program for lower-income and disabled people. It would aim to save at least 2% in total costs.

If the bill passes and the project works, it could potentially improve care for more than 100,000 people, Jeff Sanchez said. And part of the idea’s appeal, he said, is that unlike the broader changes proposed by Gov. Patrick, which are expected to unfold over several years, “We can do this now.” Longer-term reforms are needed, he said, but so are short-term measures.

“We do know that this chronically ill population can take up to 45% of MassHealth costs,” he said. “Imagine if we can bend that curve.”

But will it scale?

But a central question looms: Is it scalable? Can a pilot based at Mass General, with all that elite institution’s extra expertise, deep pockets and advanced electronic medical records systems, actually work in very different venues without so many advantages?

Dr. Gregg Meyer, retired Air Force colonel and one of the project’s parents: “We don’t know if it’s scalable,” he said. “We know it’s at least worthwhile to look, and there are lots of reasons to think it is, and that’s a place we weren’t at five years ago.”

Back then, he said, he’d have said that the pilot might be “a best case scenario.”

But things are changing, he said, from the federal push for electronic medical records to the Massachusetts move toward more global payments. “I think the ability to replicate this is going up every day. The right question to ask is, ‘Can we make it work in other environments?’ It’s all well and good to make it happen at MGH. Can it work in a rural setting? Can it happen in a small office with two physicians? What’s encouraging is that many of the enabling tools we think have made a difference are potentially scalable once you deal with certain conditions.”

Asked the same question — “Can this be scaled up?” — Dr. Eric Weil, the project’s medical director, said, “My gut instinct is that it certainly can. It would need to be adjusted for any institution. It may be that it’s far more effective in a larger Accountable Care Type institution,” but “the core components of what we’re doing can probably be extrapolated to many environments.”

Eric describes the pilot’s orientation in baseball terms: During a game, some team members will be in the dugout, some warming up and some at bat. At bat, in medical terms, is a full-fledged medical crisis that means emergency or hospital care. “You want to keep the ones that are warming up from getting to bat,” he said. “We aspire to focus on that middle tier of patients to keep them healthy and out of the hospital.”

The pilot’s intensive style of care “can be extrapolated,” Eric said, “but it’s going to take some work. If people are willing to do the work, it can be pulled off.”

Lessons from the pilot project

It’ll take not only work, but some financial courage. Mass. General invested about $100,000 initially in the project, and it is risk-based: if it does not meet Medicare’s savings targets, it has to return the monthly management fees Medicare pays it. The pilot’s staffers describe a sharp learning curve, with many lessons learned — and some elements that failed and had to be dumped — along the way.

“We’re constantly learning,” Gregg Meyer said. Among the wrong turns taken, he said:

• It doesn’t work to try to outsource care, by — for example — using an outside agency to check in on patients and try to engage them more in their care. The doctor’s office must be directly involved.
• Many complex medical patients have mental health needs, but over time it became clear that they tended to need support from a social worker and a pharmacist rather than a psychiatrist.
• It’s important to realize how “incredibly difficult” the job of a nurse care manager is. They form close bonds with the patients and then, inevitably, many of the patients die. “In some ways it’s like end-of-life care in slow motion,” he said.

Mary Neagle, the project’s manager, says it’s also become clear that the care team must be allowed to be creative, to customize, and that the nurse care managers must have the leeway to let their skills and experience guide them. And they must help patients become clear about their own health goals.

Ultimately, she said, “It’s all about the relationships.”

“A lot of it is about building trust,” Gregg Meyer acknowledges. “You don’t pull that out of a toolbox.” But patients with difficult health needs tend to be happy to talk to skilled staffers, he said, ‘to say, ‘I need help getting in to the test, or could you take the time to carefully go through my meds?’

The care management project staff offers example after example of how the program’s relationships improve patients’ health.

The man with three cancers and heart failure who used to need a hospital bed every couple of months, and now has been home more than a year. The homeless man with ten different serious diagnoses whose medicines had been stolen at his last shelter, and whose care manager helped him find a home. The 96-year-old who finally takes her medications on a regular schedule.

When Wendy Atamian first called Phyllis Minsky to offer her services as her nurse care manager about three years ago, Phyllis thought it was some sort of scam. “I was reluctant to give her any information,” she recalled.

Now, she said, “Wendy is a very good friend.”

Readers, do you have experience with care management? What do you think of this approach?

At the center of that shift, the buzzword of all buzzwords in the months to come, is “ACOs,” or Accountable Care Organizations. We offer a rudimentary guide to ACOs here. The bill that the governor filed last week briefly defines ACOs as “connected or integrated groups of health care providers that achieve improved health outcomes and lower the cost of care.”

But what does that mean? What is this shift going to look like? CommonHealth spoke today with Dr. Marc Bard, chief innovation officer in Navigant’s health care practice and author of a forthcoming book: “Accountable Care Organizations: Your Guide to Strategy, Design and Implementation.” He kindly boiled it down for us into five main points:

1. In the current system, you are your own health care general contractor. An ACO would be more like a package tour.

“American health care system” is actually an oxymoron. There is no system of care. If it resembles a system at all, it resembles an ecosystem. That’s an important concept because an ecosystem is an essentially competitive system in which each element is fighting for survival, and there’s no attempt to organize an ecosystem, it just evolves. In the US health care system, each patient — individually operating in an an entirely transactional and fragmented environment — is essentially his or her own general contractor for care.

First and foremost, an accountable care organization is designed to be a system of care, an organized, integrated system of care. It’s a little bit like booking a package tour: You sign up and it’s all coordinated for you. You don’t have to worry about booking your airfare, your hotels, the sites you’ll see. It’s all integrated because they anticipated what your needs are — it’s a package tour with a purpose, and the purpose is optimizing your health in an efficient way.

2. ACOs are organized around the patients’ needs, not the providers’.

The system right now is organized primarily around the needs of the institutions delivering the care and their capacity to deliver it, utilizing the way they’re currently organized. So the individuals accessing the so-called system have to access it on the terms of the system rather than based on their own needs.

For example, what’s amazing to me is that, with a fair degree of accuracy, my car dealer seems to know when my car needs an oil change and actually notifies me. My doctor, whom I adore, doesn’t seem to know when I need an annual exam, and doesn’t contact me. Or take my wife, who has to essentially book her mammogram exam; her bone densitometry if she’s due fo that; her colonoscopy if she’s due for that; and her pap smear — as opposed to the system recognizing that in 2012, this is what she needs and saying, ‘Let’s book them all together, one call.’ Wouldn’t that be different?

3. ACOs reward outcomes rather than activities.

Right now, the system rewards activities. You do something, you get paid for doing something. In the future, it will reward outcomes, which is critically important. So that simply providing you with a service, if it doesn’t demonstrate an outcome of improved health, ultimately will simply not be rewarded.

If I’m taking care of a patient with a chronic illness — let’s take diabetes — unless I can begin to demonstrate that under my care, his or her blood glucose is well managed, his or her sight is preserved, sensation in his or her extremities are preserved, his or her cholesterol is well mtaintained at a safe level — and I can go on and on and on – I’m simply not going to get either paid or rewarded, it depends on how extreme we go.

(Here I interjected: But so much of the outcomes are not in the hands of the provider!)

It occurs to me that I need to sit down with my patients and say, ‘Your health matters as much to me as it does to you, so how are we going to work together to make this work for you? Because we are now partners in your health. We both benefit by your good health and we both, by the way, suffer from ill health. So the real question is: How do we design the care for you and all our diabetics so that complying with what’s recommended is the easiest option? I often liken the ACO to concierge medicine for everybody.

4. ACOs reward efficiency rather than activities.

Interesting concept: If a test has already been done, and it’s required for some other reason, it would be awfully nice to be able to access the test that’s already been done and not have to repeat it. And the amount of that that goes on every day is astounding.

But also, if an ounce of prevention really is worth a pound of cure, then it starts to focus on prevention, early detection, early intervention, and avoids the more costly components of health care delivery: Emergency Room use, use of hospitalization, and so forth. So it’s really trying to anticipate rather than react, and that’s really the most fundamental change: We’re starting to reward primary care doctors for doing what they went into primary care for in the first place — which is keeping people healthy, ancitipating threats to their health and preventing them.

The number of times I saw a patient with a very early medical problem and treated them very aggressively to prevent something! There’s no glory in that. I could see a ltitle infection in a finger and know that if this infection isnt’ treated aggressively, hand infections are very, very serious. So I’d jump on it as an outpatient and the patient woudl think of me as being a little histrionic, and I’m thinking, ‘You don’t understand!’ It’s about changing the mindset around efficiency.

5. ACO’s help open the door to transparent, real-time data for everyone.

Have you ever driven a Prius? If you watch the dashboard, the dashboard actually gives you information in real-time that allows you to optimize the car’s performance. That’s the way it’s got to be in health care, for the patient and the delivery system.

Every patient selects what’s being called a “medical home” — usually a primary care doctor — but rather than care being delivered by a doctor, the care is designed and managed by a doctor and delivered by those most capable of meeting the comprehensive and integrated needs of the patient. That could be a health educator, a nutritionist, a social worker, a care coordinator, a nurse, a Nurse Practitioner, a Physician’s Assistant, a psychologist, a primary care doctor, even in some cases a specialist. And this team of people, using current available technologies, is monitoring the health status of a population of patients.

The way the system works now is: any time Marc Bard is in the presence of a doctor, with the exception of acute trauma or somethig like that, it’s because Marc Bard initiated a visit. Because the unit of measure in today’s environment is a doctor’s office visit. In the future, that health care team, using public health surveillance measures that are available– and by the way, every part of an ACO is currently operating somewhere, we’re not inventing anything new, we’re just putting it together. And so the team is monitoring the patients, and believe it or not, they’ll know if you haven’t signed up for your colonoscopy and they’ll reach out to you and say, ‘We know that this is something that you’re not looking forward to but let’s educate you a little bit about it because it’s really not so bad….”

Next: Dr. Bard makes a few predictions about how the ACO shift will play out.

Let the history books record: On Feb. 17, 2011, Massachusetts officially launched Health Care Reform II, seeking to go where no state had gone before and stem the relentless growth in medical costs by transforming the system of health care.

Amid a sea of dark business suits Thursday morning, Gov. Deval Patrick presented his plan to the Greater Boston Chamber of Commerce at the InterContinental Hotel (the proposed legislation is here). Speaking so emphatically that at one point his voice broke to a high note, he told the gathering:

“Universal health care in Massachusetts has been a resounding success, and rightly serves as a model for what’s possible for the rest of the nation, but it costs too much. Health care in Massachusetts is now universally accessible but it is not universally affordable.”

Later that day, the governor filed a bill on containing health costs and transforming the system of payment, and also held his first meeting with a “working group” of health care, business and other leaders on his plan.

Patrick described his bill as consisting of four main pieces:

1. It proposes to provide a set of standards and benchmarks for the formation of Accountable Care Organizations and other alternative payment methodologies. (That is, ways to shift the system from “fee for service,” in which providers are paid for each procedure,” to a system of “global” or “bundled” payments that put a provider on a budget for a patient’s overall care and give bonuses for quality.)

2. It empowers the commissioner of insurance to consider a wider array of factors when deciding whether to approve premium increases, including the underlying provider rates and how they compare to medical cost inflation. (Read: the state has more power to crack down on high premiums and costs.)

3. It creates an advisory council of stakeholders and consumers to monitor how payment reform is implemented.

4. The bill seeks to redirect the system of medical malpractice in favor of apology and prompt resolution, to deemphasize so-called defensive medicine.

An additional point: It sets up a new state office to act as a “one-stop shopping” point to help “innovators in the medical community” with pilots and other experiments. And its overarching aim is for new-style health care organizations with incentives for healthier patient outcomes to predominate by 2015.

Overall reaction among attendees in the hubbub after the speech appeared largely positive, but this phrase kept popping up: “The devil is in the details” and the details aren’t clear yet. You can listen to some initial thoughts from health care leaders who were there here, here, here and here. And click here for the skeptical morning-after reaction.

Excerpts of Gov. Patrick’s remarks are here, and WBUR is scheduled to air the governor’s speech in its entirety this Sunday.

It is illegal to kill. We couldn’t just give her an overdose. But we could “withhold care,” so we stopped her tube feedings to let her effectively starve to death. She lay in a hospital bed at home for nine days, slowly fading. Even knowing her wishes, and with support from the most saintly and sensitive hospice workers, it was a nightmare.

At one point, a hospice doctor told us that if my mother showed any signs of discomfort, her morphine dose could be increased. I remember snapping at him something like: “Why in the world would we wait for her to show ‘signs of discomfort’? Crank the morphine all the way up now! Why let there be even a chance of pain? The point here is for her to die, and if the morphine depresses her breathing and hastens that along, so much the better!”

It would have been good to be able to register a request for “absolutely maximal pain relief.” But there was no mechanism for that. There was no formal way to lay out our end-of-life instructions.

That is very likely to change soon. The coming thing for patients near the end of life in Massachusetts is a new official form that lets them discuss and document their choices for “life-sustaining treatments” — based on their own needs, their own preferences and what is medically appropriate. I think of it as “the final menu.”

Far more specific than a “Do Not Resuscitate” order, it asks: Would you want to be intubated? Put on a ventilator? How about dialysis? Do you want to be brought to the hospital, or remain at home? How about tube feedings? Anything else? (Personally, I think I’d write: “Please drug me up so intensively that I float into death in a happy morphine haze.” Doctors might not be able to comply, but I’d still ask. )

The form is not for everyone — unlike the health-care proxy form that everyone over 18 should fill out to designate a backup medical decision-maker. But if you have a chronic, advancing illness with no hope of recovery, you can choose to talk about your options with your clinician. Then together, and perhaps with your family as well, you convert that conversation into checks in boxes on the shocking pink form, called a MOLST, Medical Orders for LIfe-Sustaining Treatment.

The MOLST becomes a valid medical order, to be honored by all who treat you, whether the ambulance crew or nursing home staff or hospital physician. If you change your mind, you can always change your MOLST.

I call the MOLST the coming thing for two reasons: One, it’s not here yet. The form is available only in a small pilot project that has been running for just six months in Worcester, training hundreds of doctors, nurses and social workers to use the forms. The project’s managers are still evaluating it, and if it gets approval for use statewide, they want to roll it out carefully, possibly as soon as next year.

But two, those managers are already fielding frequent requests for the form, suggesting how popular it may become. The MOLST eliminates guess-work about a patient’s wishes, both for medical personnel and for families. And it is simply, appealingly explained in this 13-minute video.

MOLST in Massachusetts from Commonwealth Medicine on Vimeo.

“A lot of people hear about it, they see it, they want it,” said Andy Epstein, who co-chairs the MOLST steering committee as special assistant to the state public health commissioner. It involves “a process of discussing and communicating and ultimately honoring the patient’s wishes. and it’s very comprehensive — that’s the beauty of it.”

The MOLST is the most concrete aspect yet to emerge from a sweeping state evaluation of how to make end-of-life care here better, Ms. Epstein said.

An expert end-of-life panel plans to submit its final report to the Patrick administration, including support for the MOLST program, within weeks. But it doesn’t take a panel to determine that end-of-life care needs fixing here and across the country. From this memorable New Yorker piece titled “Letting Go” to Medicare’s finding that more than a quarter of its budget is spent on the last year of patients’ lives, it’s clear that the American medical system has a lot to learn about managing “a good death.” And that billions are spent on care that patients don’t actually want.

Projects similar to the MOLST are under way in two dozen other states, usually under the name of POLST, with the P standing for Physicians’. As with many things death-related, Oregon is leading the way. It has had its POLST forms since the 1990s, and has now even put into place a statewide electronic registry for all end-of-life orders.

But the idea is sweeping the country, as you can see in the map provided by the “POLST paradigm” project based at Oregon Health & Science University.

Of course, there was all that political fuss about “death panels” as part of the health reform debate. That was worrying, said Dr. Mary Valliere, a palliative care specialist at the University of Massachusetts Memorial Medical Center and medical consultant to the MOLST pilot team. But death panels “are exactly what we are not doing.” she said. “I do think people understand that [MOLST] is completely patient-focused and patient-driven.”

So how has it been going? These are early days yet — only about 150 patients have filled out the forms and the project evaluation will run through December. Experience is so limited that the MOLST team couldn’t find me a patient or physician with a telling story to illustrate it.

But in general, the response has been so uniformly positive that Dr. Valliere is almost waiting for the other shoe to drop, she said. (She’s a palliative care doctor, she pointed out; in her field, things tend to get worse.)

“Originally we were very conscious that this was another new form, another new process that we’re asking health care professionals to use, in an attempt to make things simpler, that in some ways could have made their jobs more time-consuming,” she said.

“But my overwhelming impression is that people have really embraced it. They do see it in the context of documenting the time and attention they’ve given to important conversations with patients, and they can hand that on to the next person in the health care system caring for the patient. It really does help to save time as well as the major goal — to provide better care, more consistent with what patients want.”

Patients and their families have tended to be very open to talking about the form, said Christine McCluskey, the MOLST outreach coordinator. There is no clear trend so far as to their choices, she said — some want all possible treatment, some decline certain options.

Initial experience suggests that the current form — an 8” by 11” sheet of paper — may be a problem, she said, because it has a certain tendency to get lost as it follows patients between health care settings: nursing home, hospital, home, rehab. Do Not Resuscitate forms are brief enough to be put on a bracelet, but the MOLST carries more information. One possible option is to shrink the sheet down to a laminated card, she said.

The project is in too early a stage to determine whether patients’ wishes as expressed on the MOLST have been followed, Ms. McCluskey said. But a recent study on Oregon’s program found that in fact, the POLST program there did indeed help patients have their wishes honored near the end of life.

In short, it’s all looking good — maybe a little too good.

Said Jena Adams, the MOLST project director: “My main concern right now is that so many people want this, there’s huge interest in it. But I think we’re going to recommend strongly that there be a strategic process for statewide rollout, so people receive the appropriate training and so there’s fidelity and it’s used correctly. The last thing we want is to just put a form up there on a Website and have people using it in all kinds of ways that were maybe not intended or are uninformed.”

But it’s a Do-It-Yourself world these days, I pressed her. I really like the look of the form. Why not just print it out and use it? And spread it around among friends and relatives who may be near the end?
It took some doing, but Ms. Adams dissuaded me. The form is not supposed to be filled out by patients, she emphasized. It’s a medical document that has to be completed by a clinician, and signed by both doctor and patient, or it holds no authority and may not be honored. And as a patient, you need your doctor’s expertise to help you understand your outlook and your options.

If the form is appealing, she said, you can print it out and talk about it with your health care proxy or your doctor, if you’re near the end of life.

“It’s really intended as a communication tool among clinicians” she said. “That’s what medical orders are. And it’s a way to transfer information from one health care professional to another across settings. But the excellent part is that it’s all based on patient preferences.”

Unlike the form, she added, “the real conversation that has to happen isn’t full of medical jargon. It’s about your values and quality of life. ‘This is what’s important to me: I want to live long enough to see my grandson graduate from college, or I don’t want to be in the hospital in the ICU for weeks on end, or I don’t want to not be able to communicate with my loved ones.’ How that connects with all the medical treatment options and decision-making, that’s where the clinician has to come in and connect the dots, and figure out a plan that’s going to best meet the patient’s desires.”

“It just points to the importance of those conversations,” she said.

Step into the downtown Boston office of Commonwealth Care Alliance, and the first thing that hits you are the walls — they’re a screaming, deliciously bright shade of orange — not the typical palette for a health care business. But that’s the point.

As CEO of this unorthdox hybrid — part health care provider, part HMO, part payer — Dr. Bob Master must take on multiple roles. “We have to play the insurance game,” he says. “But that’s not our primary role.”

Reinventing Primary Care

Dr. Master’s ultimate role has been to re-imagine health care delivery. Commonwealth Care front-loads primary care and supports physicians in its network with a dedicated team of nurse practitioners, mental health and behavioral specialists, geriatric social workers and “every medical and surgical specialist known to man.”

The organization is essentially a full-service provider of medical care and social support for chronically sick, elderly and sometimes disabled people on Medicare, Medicaid, or both. From the moment a patient signs on, he or she has access — 24 hours a day, 7 days a week — to a nurse practitioner who is armed with up-to-date electronic medical records and has the authority to call in other specialists as needed. Patients can choose from 25 primary care sites around the state, and for the homebound, house calls are also part of the plan. For those who need to get to the hospital, Commonwealth Care contracts with 8 hospitals in the state, but will only use providers who agree to Medicare reimbursement rates

Continuity of care is essential. So the program offers non-traditional assistance to patients at no extra cost, including transportation to medical appointments and help with daily chores and activities. Commonwealth Care tries to rescue patients from the kind of fragmented, procedure-driven care that can leave them feeling like “an anonymous piece of baggage on a never ending airport conveyor belt, always tagged for the wrong destination,” as one senior put it.

Dr. Master, an internist and former medical director of the state’s Medicaid program under Michael Dukakis, has been talking about “Accountable Care Organizations” “Medical Homes” and “Global Payments” for years — long before those terms became the buzzwords of health reform, both state and national. “For years, there’s been so much noise out there,” about how to reform the payment and delivery system, Dr. Master says. But now, things may be shifting. Donald Berwick, the new head of the Centers for Medicare and Medicaid in Washington, is ready to start spending money on innovative health care models around the country. And in Massachusetts, four years after passing health reform and after achieving nearly universal insurance coverage, lawmakers are under intense pressure to control costs.

“How are you going to bend the medical cost curve?” asks Master. “This is it.”

The Most Frail and Medically Complex

CCA, which started in 2004 (after earlier iterations) operates three distinct programs. The first, with about 2,800 enrollees, is for medically fragile elderly patients, 70 percent who are homebound or eligible to enter a nursing home. These patients are deemed (in scary bureacrat-ese) as ‘dual eligibles’ because they qualify for both Medicare and Medicaid. To make this plan work, Dr. Master and others won approval to pool monthly capitated Medicare and Medicaid payments into one stream (you can only imagine how painfully complicated this seemingly straightforward task must have been).

The second program, with about 300 enrollees, is for younger, Medicaid patients with severe disabilities such as spinal cord injuries, advanced cerebral palsy and muscular dystrophy.

In January, Dr. Master launched a new project with Network Health (one of the state’s Medicaid managed care organizations) and Cambridge Health Alliance, that serves about 2,300 people, mostly on Medicaid, with terribly complex chronic conditions. These people suffer from multiple late stage diseases, like diabetes, for instance, but many are also active substance abusers with severe mental illness such as schizophrenia and other behavioral problems. In addition to the medical team, this program will deploy a group of community health workers to keep people engaged in their treatment — from keeping appointments and managing medications, to dealing with social problems and accessing social services. (More on this in another post).

Achieving Savings

Dr. Master is able to re-invest cash into his uber-primary care network through savings achieved by reducing hospitalizations and nursing home placements.

Here are some numbers:

– In 2008, CCA invested $3.24 million in primary care enhancements above what Medicare would have paid.

– CCA’s hospital use is 55% what would be predicted based on the risk scores of its patient population (Overall savings are in the range of $500 per person, per month, Dr. Master says); nursing home placement is about 75% of what would be predicted.

–Among CCA’s homebound elderly, their annual medical expense rate increased 3.8 percent between 2004-2009 (compare that to the general population with a yearly medical expense rate that increased around 7-10 percent.)

–Among CCA’s ambulatory elderly, the annual medical expense rate rose 0.2 percent.

“Rationalizing” Health Care

Some in the health care world think that what Commonwealth Care does is so unique that it can’t be replicated. And some believe that when lawmakers talk about “payment reform” it’s really just a way of shifting costs from insurers to providers.

Others think Dr. Master is on the right track.

Michael Porter, a professor at Harvard Business School and a leading authority on competitiveness strategy and health care delivery, co-wrote a case study of CCA in 2008 with Jennifer Baron, a senior researcher at Harvard Business School.

Ms. Baron told me that she thinks that Commonwealth Care’s approach of focusing on a particular patient population is very applicable to the greater population, “and in that sense the state and country can and should learn from the CCA model.”

But, she says, the key is to develop deep expertise and understanding in a particular population, and not just assume that one size fits all. “What works best can vary greatly across patient populations,” Ms. Baron says. “The activities that create value for frail elderly or disabled individuals differ widely from the activities that will improve patient health and efficiency of care delivery for healthy children or adults with certain chronic diseases.”

Indeed, when Dr. Master talks about “rationalizing,” rather than “rationing” health care, what he really means is figuring out each individual’s specific needs and then delivering appropriate care, hopefully, before an emergency erupts.

Freedom for Docs

The first step for a new enrollee is an in-depth intake assessment with members of the medical team. Together, they create a comprehensive care plan that identifies what additional support, long term care, drugs etc, the patient might need.

That’s typically followed by a visit to the primary care doctor, who is essentially free to practice medicine, no longer having to deal with the social issues and other complex non-medical obstacles that can undermine a patient’s health. Under this model, the doctor is “leveraging knowledge and expertise, and not having to be the first responder, the data gatherer,” Dr. Master says.

“The idea that physicians are completely responsible for coordinating care is illusionary,” he says. “We do away with that illusion.”

(Future Posts That Focus on CCA Patients and Providers Will Follow)