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The Catalyst

Future of health care arrives with pilot plan

By Dawn Brazell
Public Relations

This month thousands of MUSC employees may opt into a new state health plan that is part of a state pilot program.

Dr. William Moran (center)  and resident Dr. Chad Kurzynske do “teach back”with patient
Erica Ingram.
Photo by Sarah Pack, Public Relations

The state Budget and Control Board approved MUSC’s collaboration with the S.C. Public Employee Benefit Authority to offer this type of plan to employees. The pilot will begin Jan. 1 and is expected to run two to three years, providing critical data for the development of plans that can be adopted across the state. It is based on a patient-centered medical home model.
Patrick J. Cawley, M.D., MUSC vice president for clinical operations and executive director of the Medical University Hospital Authority, said MUSC has been laying the groundwork for this for awhile.

A patient-centered medical home strategy team has been meeting for several years to prepare this model, and there’s been a separate group with a large number of enthusiastic supporters working to get the PEBA pilot plan on course, including core team members: Mark Lyles, M.D., chief strategic officer for the MUSC clinical enterprise; Karyn Rae, managed care; Betts Ellis, MUHA; Mark Stimpson and Dee Crawford of University Human Resources; David McLean, MUHA Legal Counsel; and Mark Sweatman, MUSC special assistant to the president, Columbia office.

The next decade will bring radical changes to health care delivery, he said. Beyond this pilot project, hospitals are going to have massive capabilities when it comes to analytics, data and patient information.

“Combine this model,” Cawley said of the electronic medical records that have been put in place, “with the future of genomics and knowledge about our own genes — combine all three of those things — and we’re looking at a very different type of care during the next 10 years and here at MUSC. We feel as a traditional academic medical center, we need to be on the cutting edge of that testing of what works and what doesn’t work. That is what we do best.”

The patient-centered family home model

Watch a Video

It’s a conversation you might expect in a classroom, but this one is taking place during Erica Ingram’s visit with her internist, William Moran, M.D.

“So tell me what medicines are you going to take?” he asks about controlling her asthma. She answers correctly, and then he asks more questions about how she’ll handle those times when her peak airflow rate drops.

“This is called teach back,” Moran said, pausing in the question-and-answer session. “What do we teach you, and what can you teach back to me? We have written details here in case you forget,” he said, handing her an instruction sheet.

“That’s why the team approach is great. I’m like Coach (Bill) Belichick (New England Patriots head coach) – let’s make a different play next time to keep her out of the emergency department.”

That teach-back philosophy is one reason Ingram is here at University Internal Medicine, which practices a patient-centered medical home model in the delivery of health care. The 22-year-old wants to become an occupational therapist and is savvy to the difference in medical models. For example, she likes that they are doing a medication reconciliation to ensure she’s on the best medicines for her condition and that they don’t conflict with each other. She has not only her doctors, but also a pharmacist on her medical team who will review her medications.

LPN Melissa Nolan checks on Erica Ingram’s vital signs. Photo by Sarah Pack, Public Relations

“I like to have a holistic approach to my health care,” she said. “I like being a part of a medical team.”

It shows, as Ingram pops back answers to Moran. She’s as motivated as her team to manage her asthma as well as she can. This health care model depends on patient participation and empowerment.

Patrick J. Cawley, M.D., MUSC vice president for clinical operations and executive director of the Medical University Hospital Authority, said it’s the perfect timing for MUSC’s collaboration with the South Carolina Public Employee Benefit Authority
to offer this type of plan to MUSC employees.

“We were ecstatic about this,” Cawley said. “We’ve had a group here at MUSC working with a group at PEBA since April. They’ve been working very hard, meeting almost every week working out the details of the plan. At the beginning, I thought there was a slim chance we’d have it done for January 2014, but the group worked hard, and they got it done. We want to try this at MUSC, so that’s why we got moving quickly.”

Cost Containment
The reason MUSC is the perfect collaborator with PEBA is that most employees already receive their care at MUSC, Cawley said. The plan offers a way for employees and MUSC to avoid the 10 to 15 percent rise in insurance premium costs in exchange for using the plan.

“These are our own employees, and they are likelier to work with us and perfect our plan. We’re seeing our cost of care go up very fast. We think we have an opportunity to intervene and do something about that. The way this works is we are going to provide financial incentives for the patient to get their care through the patient-centered medical home. It’s less expensive care and better care.”

The primary care physician serves as the hub of a team of care providers in this model. All the primary care parts of MUSC will be involved: Carolina Family Care, General Internal Medicine, General Pediatrics and Family Medicine – and all are or will be certified as patient-centered medical homes before January.

Controlling rising medical costs is the number one driver of this plan, but not the only one. “The second reason is that as a health care provider, we’re in a very unique circumstance to provide health care in a way that’s innovative and different. A car builder can’t provide health care to their employees but we can,” Cawley said. “The third reason to do it is that we’re the state’s leading educator in terms of medical education. We have to teach the next generation of nurses, and medical students and physical therapists et cetera how to practice medicine that’s better quality at a less expensive cost.”

One way is patient empowerment.

“I’m a physician and have dedicated my entire career to quality improvement and continuous improvement,” Cawley said. “We need a feedback loop here and the feedback loop is the patient. We can put this plan together, but we really need to seek input to see if it’s working the way it should be. If it’s not we need to modify and tweak it. It’s called the continuous learning wheel.”

Another driving force is better data. Eighty percent of the health care dollars are spent by 20 percent of the population. In the patient-centered medical care model, the team does triage on its patients by figuring how to better deal with sicker patients so they get the preventive care they need and reduce costs, while still offering easy access to its healthier population.

Cawley said the primary care providers will be looking at the high utilizers, a task made easier by the use of electronic medical records, and doing strategic outreach so that patients with such conditions as diabetes or high blood pressure, for example, get the preventive care they need. “Medical care is incredibly complicated – it’s one of the most complicated things we do across any business in the United States. We simply have not had the tools.”

Now that’s changing, especially with electronic medical records. “If you don’t have the data, you can’t do the reaching out. It’s data that needs to be monitored to see what’s working and not working and who is not showing up.”

Data Rules

Mention data, and Moran’s face lights up. With extensive experience in a patient-centered medical home model and is trained as an epidemiologist, he knows what a difference data can make as a division director and a UIM physician.

“We need to build experience in this,” he said. “Most people here have never been exposed to a managed-care model. There’s also not a lot of experience within MUSC with managed care, and there’s not a lot of experience with ‘tell me my numbers.’”
Moran said he has gone to family care doctors and asked what their control rate with blood pressure is for their patients and gotten the response that they think it is “pretty good.”

“I can tell them mine is 69 percent, and I can tell you the patients who are out of control and that we’re working with. Working with data is working with populations. That’s one of the huge things we’ve developed with UIM. We have incredible data management. It’s tough to look good when you don’t know your numbers. You don’t know how well you’re doing.”

On his staff is health economist Patrick Mauldin, Ph.D., who has more than 20 years experience and can be called anytime for data reports. If Moran wants to see what hospital readmissions are for nursing home patients, for example, he gives Mauldin a call and two minutes later he has the data he needs, he said. If he wants to know which patients aren’t showing up for their appointments, he can find that out, too.

Moran said he worries most about the patients not showing up.“If you’re not coming into clinic, you’re much likelier to end up in the ED or the hospital. If you cancel or are a no show for an appointment, it dramatically increases your chances of ending up in the hospital, particularly for certain diseases. If it’s ‘I’m too sick to go to the doctor,’ that’s not a good sign.”

Thinking Outside the Box

Moran said he and the many others serving on MUSC’s Patient-Centered Medical Home strategy team love the challenge of setting up better health care delivery models.“There are a lot of reasons why people access services the way they do. We have to build a system that patients like to use — and prefer to use — rather than alternatives like the ER that are more expensive.

His nurses have 1,400 patients each to manage, which may sound like a large load, except only 20 percent have health conditions that require frequent care. Seventy percent of the patients are young and relatively healthy. The question for those patients is how to facilitate their access and care since they generally have jobs and busy schedules. One solution is electronic visits for straight-forward cases, which saves time for the patient and physician.

“How many electronic visits can I do in an hour? A lot. Then my time is reserved for those really sick patients who need to talk for awhile,” Moran said.

Health care providers on a patient-centered model focus on better patient education.

“So when you do a foot exam for a diabetic and do education about how to not get an ulcer on your foot, it’s a worthwhile investment,” he said, citing statistics about the costs of amputations on the health care system.“Eyesight is the same way. What’s the cost of blindness? If you can laser a diabetic’s eyes and prevent blindness, that’s a good thing,” Moran said.

Editor’s note: To see the full multimedia package, visit MUSC News Center,

October 24, 2013

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