Triggered in large part by health care reform, primary care in Hawaii is still undergoing major change in an effort to provide higher-quality care for more people at a reasonable cost. Previously, this column described how the Hawaii Medical Service Association, the state’s largest health insurer, has thrown its weight behind a concept called the patient-centered medical home, where your primary care physician’s clinic becomes your "home" for coordinating health care. The medical home has the laudable goal of improving the partnership between patients and doctors and relies heavily on electronic medical records to ensure optimal efficiency and positive outcomes. Doctors get reimbursed more if they participate in this effort.
The patient-centered medical home, however, does not address what happens to people without a primary physician or those who choose to go outside of the medical home for emergency or specialized care. For certain populations, high rates of hospital admission and inappropriate or inefficient use of emergency departments and specialists remain expensive and problematic.
Ho‘okele Health Navigators is one company whose services have seen an increased demand under health care reform. Ho‘okele works in partnership with providers to coordinate care for the sickest and most fragile of their practice.
"We use an RN care coordinator together with in-home health monitoring technology in an effort to customize care for individual needs," said Ho‘okele CEO Dew-Anne Langcaon. Efforts are also directed toward managing barriers to care, insurance issues, transportation and family concerns. This program works to reduce costs by decreasing avoidable hospital admissions and emergency department visits.
Still, to optimize costs while ensuring maximum efficiency and coordination of care, payers are becoming increasingly interested in more comprehensive, systemwide solutions. Physician hospital organizations (PHOs) are another program aimed at bringing primary care physicians into closer collaboration with hospitals, specialists and skilled nursing facilities.
The PHO participants pool administrative resources, enhance communication and minimize waste. PHOs utilize electronic health records to collect, analyze and share information. They also create an opportunity to share preventive and educational resources for patients. They can help prevent duplicated tests or other services.
Is this good for the people of Hawaii? It cuts both ways. Certainly, there is an upside potential to sharing information and common costs. On the other hand, both patients and providers worry that as health care becomes increasingly regulated and systematized, their experience will become less personal and less sensitive to the specific needs of each individual.
The patient-centered medical home and physician hospital organizations are structural solutions to the art of medical care. While they hold the promise of improving care and cutting costs, they also create a new set of hoops the physician must jump through. Instead of looking into the eyes of the patient, the doctor could end up staring mostly at the computer screen as she inputs information to keep up with the new set of standards.
We must continue to work to evolve our system in a way that manages costs and optimizes outcomes but does not lose sight of the sacred relationship between patient and doctor.
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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 info@manakaiomalama.com.
