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HMSA initiative cuts costs and treats 'whole patient'

By Ira Zunin

LAST UPDATED: 11:37 p.m. HST, Aug 5, 2011

This month, HMSA launched the Patient Centered Medical Home (PCMH), a new initiative affecting health care delivery for Hawaii's clients and providers. HMSA's health maintenance organization patients are now being assigned to clinics that have agreed to participate. Health care teams in PCMH-qualified facilities will be responsible to not only treat physical illness, but also to engage in prevention, health education and screening for ailments of both mind and body.

HMSA is driving this transition with significant changes to the existing reimbursement model. To begin, fee-for-service rates are now frozen at 2010 levels and not subject to the usual annual increase. Instead, to help meet the rising costs of health care delivery, participating clinics will receive a modest per-member-per-month (PMPM) fee for each assigned patient. The monthly fee is increased for meaningful use of electronic medical records (EMR). In addition, to the extent these facilities meet set criteria that HMSA attributes to quality, safety and efficiency, they also will receive a quarterly, pay-for-performance incentive. Finally, HMSA has proposed to share with providers some of the realized annual cost savings.

Integrative medicine, which aims to bring together the best of modern medicine and traditional healing arts in a "whole patient" approach, is ideally suited for this concept. It emphasizes collaborative, multidisciplinary care delivered with cultural sensitivity and a biopsychosocial approach. In these settings, primary care doctors and specialists typically work in concert with nurse practitioners, physical therapists, psychologists, nutritionists and acupuncturists. This expanded tool set provides an opportunity to prevent and manage illness in a customized and cost-effective manner with a view toward optimal health.

According to Dr. Josh Green, Senate health chairman and medical director of the Hawaii Independent Physicians Association, "The PCMH concept harkens back to old school primary care medicine but with the addition of new collaborations that have emerged as the medical system has evolved.The intention of the PCMH is to create a place for patients in which they will feel comfortable coordinating all of their medical care. Primary care physicians are intended to lead the effort and work with an expanded team of providers to create a full-service medical home."

Patients and physicians wonder whether the initiative will result in a patient-centered medical home or a payer-centered medical jail. Certainly, PCMH is expected to further improve HMSA's bottom line. Patients are sometimes unsure whether they will lose the cherished one-to-one relationship with their physician or gain a team that is collaborating for their benefit.

Some physicians worry that they are being forced to practice health care in a fashion that is too "cookbook" and overly homogenized. They wonder whether PCMH and EMR will erode the art of medicine. Also, for individual or smaller practices, the cost and labor resource required to convert to EMR is simply daunting. For many practices it also will be difficult to expand the team to take on still greater responsibilities for patient care and education.

The Hawaii IPA is an early adopter of this new platform, and many of its member practices have already signed on. According to Green, "The goal of the PCMH for society is to deliver the best care for our citizens while reining in explosive costs that too many people can no longer afford."

Ira Zunin, M.D., M.P.H., M.B.A., is medical director of Manakai o Malama Integrative Healthcare Group and Rehabilitation Center and CEO of Global Advisory Services Inc. Please submit your questions to

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