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February 2012

Home Remedy

Can an Adirondack program fix national health care?

Photographs from iStock

I never thought my practice would be on the leading edge of health-care reform. Sure, I said I knew how to fix health care, but that was at a cocktail party after a few drinks, a lot of egging on, and long before I spent years drowning in paperwork. When I took a job just outside the Blue Line I figured I’d live and die as a kind of sexy, self-sufficient, medical Anne LaBastille, a doctor who could wring a chicken’s neck or rev a chain saw right be­fore she slipped into a sequined jacket for dinner at the club. Chain saw, check. Chickens, check. I never did find the jacket.

Instead, in 2010, I found the Adi­rondack Re­gion Medical Home Pi­lot, and ready or not, along with hundreds of other primary-care providers, I am set to change health care. The pilot is a contract be­tween insurance companies and primary-care physicians and is based on the premise that if given higher reimbursement, doctors will use the extra resources to deliver higher quality, lower cost health care. The relationship between a patient and a personal physician can then focus on preventive care, access to care and care coordination. The country is watching. At least the think tanks interested in reform are watching. I’m afraid the people who matter the most, the patients, are unaware.

I came to work in the North Country in the midst of a snowstorm in 2002, driving from Arkansas, where the only snow we saw was on TV at Christmastime.

My son mumbled in the back seat while I drove. The quilt slipped off his lap and he was too far from the heater vent. He was 18 months old and a handful of years away from hospice care. I drove on gas fumes that were as thin as our bank account. We’d dipped past our savings into credit to pay medical bills.

Ten years later, after using the health-care system from all possible angles, I look at medicine with binocular vision, as a mother of a chronically ill child and as a doctor. My son died. The bills and the lessons I learned about health care persist. Now I’m in the middle of a pilot that, whether it succeeds or fails, could change medicine forever.

What’s wrong with health care from a patient’s standpoint? Communication, cost and quality. What’s wrong with it from a provider’s standpoint? Well, the same three things.

Health care in the Adirondacks is a microcosm of the morass of medicine in our country—too many chronically ill pa­tients, too much paperwork and not enough primary-care providers. Throw in malpractice insurance and oversight by regulatory bodies and put the whole mess in areas of wilderness so dense the doctors’ offices are tiny oases of warmth. Health-care delivery seems onerous if not impossible.

The pilot is a gamble: whether primary-care physicians, through self monitoring and care management, can provide more efficient and higher quality medicine.

Because so much of what has occurred has been in the infrastructure, patients still don’t see the changes—policies and procedures and software up­grades. We transitioned our offices to electronic re­cords, likely what patients have noticed. They won’t realize the safety features and cost savings behind electronic prescriptions, but they’ll know the doctors in Newcomb, Elizabethtown and elsewhere have the latest technology even if they still wear plaid flannel shirts to the office.

Much of the pilot involves electronic reports. Tracking labs and referrals, and providing same-day appointments for people who need to be seen are realities now. Closing the loop of health care, the one that patients slip out of all the time, is the payoff. Three years ago, I ordered lab tests on a wish and a prayer that the results would find their way through paper trails and human error to my desk, where I could interpret the results and affect lives. Now the lab order goes electronically into a file of pending tests. If a lab isn’t drawn, I know why and I still close the loop.

I’m the same caliber doctor I was two years ago. I still make the same mind-blowing diagnoses. I barely have to take a history, much less touch anyone. But for the days I’m human, I have better tools now, and more are coming. Soon I’ll access a statewide health-information network and see my patient’s ER visit and subspecialists’ reports without waiting for a pile of faxes to be sorted, triaged and filed.

My pilot colleagues from Bolton Landing to Tupper Lake have teamed up with other unlikely partners. On a regular basis, I travel to Albany to discuss the program. I join insurance companies that have the resources to pay for culture change and hospital administrators who have the business savvy I lack. I didn’t sit down with them by choice, and they weren’t exactly tickled to join hands either. And none of us has started singing “Kumbaya.” They need to trust that practitioners know more than just how to diagnose high blood pressure, that there is value in our experience on the front line of medicine, and value in the doctor/patient relationship. We need to believe that payers deserve a different label than just payers, that there is another dimension to their identities besides just a checkbook.

I worry the pilot might be in jeopardy. Payers have limited their vision of culture change to a goal that must be achieved in a short time. The prov­iders have circled around the data like a campfire they don’t want to share. Some of us even argue we don’t need better tools. We have a chain saw; we don’t need a chisel too.

But if we can work together we’ll utilize the ultimate tool our society needs to keep up with the complexity of medicine: collaboration. I thought about the problems in health care a lot after I had my son. On my days off work I would transfer him from his wheelchair into the canoe at Fish Creek and tighten his life preserver before I pushed us away from the bank. The sophistication and complexity of medicine kept my son alive for nine years. But I hate that parents like me and patients like him ever had to worry that lab tests weren’t checked or that subspecialists wouldn’t get the MRI results, or that any of us were left adrift to navigate the system alone.

I have other children now, but I still work late because what I do in the pilot could effect a change in health care that would ripple across the country. When I come down the driveway at night, my family waits and the moon lifts above the icy lake and tips over the birch branches.

My youngest daughter dances when she sees my truck. She looks like my son, but unlike him, she can reach up with both hands and jump. She stretches up to the moon, a yellow balloon hovering over the deck. Her breath is a cloud and I tell her to go in, it’s too cold. But she jumps again and her fingers slip out of her mittens and wiggle in the light and I swear, I swear she can touch the moon.

Learn more about the Adirondack Region Medical Home Pilot by visiting www.adkmedicalhome.org.

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