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Monday, May 24, 2010

A New Model in Medical Care

By Michael Vitez, Inquirer Staff Writer

After 25 years as a family physician, the joy of medicine was gone for Joseph Mambu.

He'd spent 22 years in a practice big into HMOs, across from Abington Memorial Hospital, but felt that model never lived up to its promise. When he and his partners sold to Holy Redeemer Hospital a few miles away, Mambu struggled with being an employee with little control.

His wife, Angie Palmgren, a nurse, told him he was so unhappy he looked as though he were dying. She urged him to follow his gut, to take the risk he had been dreaming of.

So at 52, Mambu started his own practice. He wanted to make house calls, restore the best of the old-fashioned family doctor, and somehow make it work in an environment that scholars have dubbed "Hamster Care," reflecting the daily scramble to see more and more patients.

"My kids are grown; this is my last chance," he said to himself at the time.

"I had the money and the desire. Instead of going to Europe and taking vacations, this is what I did. Something was inside of me that needed to be real."

The system of primary care in America was broken and Mambu was hardly alone among his peers in feeling dispirited and overwhelmed.

When he launched in 2001, Mambu didn't know where he was headed. Now he's at the vanguard of a movement sweeping America – the patient-centered medical home – in which physicians have more time for complex cases and are much more proactive in promoting the health of all patients, who have same-day access to their medical team.

The new health bill Congress passed forcefully promotes this model, and many experts call it the future of primary care, its salvation.

How does this model work?

And has Mambu found the practice he was seeking?

Testing a New Model

For four years, Mambu worked 80-hour weeks to build his new practice, Family Medicine, Geriatrics & Wellness, in Lower Gwynedd.

He teamed with Lisa Albert, a nurse practitioner, and with his wife. They offered evening and weekend hours, and Internet access for appointments. He was happier, but his pay was still based on volume, with the reimbursement shrinking. He had to see so many patients to stay afloat, and he was burning out.

In 2005, Mambu was accepted into the TransforMED Demonstration Project run by the American Academy of Family Physicians.

Fewer than 5 percent of medical school graduates were choosing primary care. A new model needed to be created. This project was going to be the laboratory.

Just 36 practices in America were accepted. Mambu was the only Pennsylvanian.

"Our role was to begin the reformation," Mambu said.

At first, there was no mention of the patient-centered medical home. But as the project evolved, "it crystallized, became sexy and well known," he said.

Here are the central tenets:

  • Every patient has a relationship with a doctor. Those who do are sick less often and have fewer chronic illnesses.
  • The doctor is part of a team, and focuses on the sickest patients.
  • The team coordinates a patient's care, wherever he or she is, no matter how many specialists are involved.
  • Access is easy. Same-day appointments. Patients can call and e-mail with doctors.
  • Electronic medical records allow the team to manage all patients, not just those who come to the office.
  • Medical homes will be paid more – in recognition of better health of patients and anticipated savings to employers and insurers.

For two years, experts from TransforMED pushed Mambu to make these changes. They called nearly every day, and the group met often.

"It was like rocket fuel for my practice," Mambu said.

Rediscovering His Passion

Mambu, who graduated from Frankford High School in Philadelphia, jokes that his family name was Italian, Mambuca, but was lopped by immigration officials and now sounds African. Now 62, he came of age in the Marcus Welby era and, with his gray hair and gentle manner, could well be cast by Hollywood as a family physician. He even carries on house calls the black leather bag his parents gave him 35 years ago when he graduated from Thomas Jefferson University Medical School.

Mambu says he has rediscovered what he loved about medicine in the first place, what he calls "that metaphysical magic that happens when two human beings come together, one with a problem and the other with a desire and knowledge to help."

He has been able to average 20 patients a day, even 15, down from about 30 a day for many family physicians. "I hardly ever see a runny nose anymore," he said.

Mambu spends one third of his time in the office, one third on house calls, and one third at the hospital, primarily Abington. He says the time spent out of the office makes him a better doctor, always learning.

For instance, one patient, 89, had collapsed at her stove while cooking chicken.

Everyone thought she had had a heart attack, based on soaring levels of one enzyme, troponin, a classic indicator.

But it turned out her fall was caused by a bad leg.

Visiting the patient at the hospital, which few family doctors do anymore, Mambu ran into her cardiologist, and so appreciated hearing his explanation: As the woman lay on the floor with her kitchen filling with smoke, she feared she would die and suffered a "stunned myocardium" – a blast of adrenaline to the heart, which can at first look like a heart attack.

On his way back to his office for evening hours, Mambu stopped at the home of Helen Glynn, 86, a widow who has been in bed for 12 years.

Mambu says Glynn is an example of somebody whom he and his team keep out of the hospital and nursing home because of their visits.

Twenty percent of Medicare patients consume 80 percent of Medicare dollars – more than $400 billion a year. They are often people like Glynn, with many chronic problems and repeated and expensive hospitalizations.

The idea is to keep the patient healthier and the overall cost of care down.

Whether the model works will take years of study to determine.

Mambu greeted Glynn and asked permission to allow a reporter and photographer to observe. Then he said to her, "Let me take your blood pressure. I wonder what it is with three men in your bedroom." He smiled and added: "When was the last time you had three men in your bedroom?"

"Never!" she replied.

Glynn was happy, and her skin was as pink as her spirits, remarkable considering that she's been in bed so long that her feet have become disfigured - "gravity dislocates them," Mambu said. He pointed out how wide her middle had become - also typical of people in bed for so long.

On a previous visit, Mambu did a small surgical procedure – he cut a skin polyp, a "tag," off her back.

Another tenet of the model is to be a doctor, do more yourself, do what you can do.

Her back looked fine. He bid her farewell.

'No Other Way to Practice'

Mambu's practice added two physicians - Hillary Marcus and Daila Pravs. Pravs joined two years ago after finishing her residency at Jefferson. She joined because of the medical home.

"In my mind there is no other way to practice," she said.

Pravs is a rarity – the young doctor who chose not to take what is known as "The ROAD" – radiology, orthopedics, anesthesia, or dermatology, well-paid specialities.

"I was told my board scores were too good to go into family medicine," she said. "I was told to pursue a career where I could make more money."

She loves building relationships and focusing on the whole person but notes the long hours and "calls on our cell phones in the middle of the night."

Mambu's practice also has two nurse practitioners, Lisa Albert and Amy Lorenzo.

Mambu calls Albert "my right arm."

She spends most days in the community. Not long ago, she went to meet Mary Berman, 94, who lives independently at the Lafayette-Redeemer retirement community in Northeast Philadelphia.

The patient heard about the practice from neighbors, and was tired of riding the "bumpy bus" in the cold to doctors' offices. "I decided to indulge myself," Berman said, "and choose a doctor who makes house calls."

Berman, a widow living alone, was legally blind from macular degeneration. She told Albert she knew her eyes were getting worse because "the bingo cards are getting harder to see."

Albert did a physical exam, reviewed medications, toured the apartment.

She decided to have visiting nurses come several times to check Berman's blood pressure, which was high, and also get occupational therapists to do an assessment of her apartment.

Albert felt Berman was at risk of suffering a fall.

"When you see someone in their home, you spot things you can't see in the office," Albert said. "Seniors tend to present a good front and often want you to think they're doing better than they are."

Albert was spending money now to avoid a crisis later.

"What if Mary Berman has a stroke, or falls and breaks a hip?" Albert said. "Compare the cost of either of those against the cost of a few visits by a nurse and therapist."

Patients Bear Responsibility

An older man saw Mambu for a bad leg wound. If diligent in his wound care, the man could avoid the hospital.

The patient then went to see Palmgren, the nurse, who spent 20 minutes showing him how to clean the wound, insisting that he do that twice a day and encouraging him that he could do it himself.

He was back after a week. The wound was half the size, Palmgren said. The patient hated cleaning it, but she encouraged him to continue.

Education is fundamental, as is patient responsibility.

Mambu asks how many family doctors have an RN who can spend that kind of time. (A second RN, Charlotte Mayer, joined part-time last year.)

When men with diabetes don't want to exercise or give up salt, sugar, and fatty foods, Palmgren gets out the book on erectile dysfunction and shows them what diabetes can do to them. That usually gets them on board.

Adopting Electronic Records

In 2007, Mambu said, he invested $100,000 of his own to buy an electronic-records system. This is vital.

Jessica Schmitt, practice administrator, said that with the new system, if there's a drug recall, she can easily contact every patient who uses that drug.

She can see how many patients referred to specialists actually went, because a report would go into a patient's electronic chart. Staff can follow up with those who don't go.

Patients can log in from home and see test results, and doctors and nurses can e-mail patients without risk of violating privacy laws.

When an elderly patient in his office last winter with osteoporosis said she didn't remember having a bone-density exam in years, Mambu clicked one key on his laptop and told her she had one less than a year ago.

"Could they have made a mistake?" she asked.

Another keystroke and the actual report was on his screen, dated March 2009.

Mambu said the transition to electronic records wasn't easy. "There's an investment in time, and change and angst, and change fatigue, and it goes on for months and months, and sometimes you don't see any progress," he said. "And you're doing this as a leap of faith right now. Will payment evolve? Will there be reform to fund this kind of development?"

Incentive From Insurers

When Mambu finished with TransforMED, in 2008, he joined the governor's "learning collaborative," a group of 32 primary-care practices in the region. Each was certified as a medical home or pledged to become one.

These doctors also agreed to track all diabetics and report overall performance in key measures each month.

In exchange, six regional insurers – including Independence Blue Cross and Aetna – agreed to pay an additional $12.5 million over three years to the 32 members.

For Mambu, that's about $100,000 a year – nearly 10 percent of his practice's revenue.

"That has made a difference between black and red," he said.

Mambu is tracking all 107 of his diabetic patients. From June 2008 to last month, 33 percent more patients than before had eye exams, 56 percent more had foot exams, and 87 percent more set goals – losing weight or dropping blood pressure.

Though Mambu does well on some measures, on others his practice still falls short.

For instance, the group's goal is that 70 percent of diabetes patients should have blood pressure at or below 130/80. Mambu's practice has 43 percent. (If a diabetic hasn't been measured in a year, he is counted among the unacceptable 57 percent.)

"After becoming a medical home, your numbers don't just improve and stay that way," Schmitt said. "That is why we monitor them constantly. Before, we didn't have a good idea what was going on with our entire population of diabetics, but now we do."

Ann Torregrossa, director of the Governor's Office of Health Care Reform, said that initial results had been promising and that six more collaboratives had been established in the state, now including 800 primary-care doctors reaching 1.2 million people.

She said the collaboratives would gradually measure more chronic illnesses, such as obesity and heart disease.

Looking at results for March, she said Mambu's practice was doing well.

"Kidney screens, he's at 90," she said, "63 for the collaborative. His diabetics with LDL cholesterol readings at or below 100 is 55, and it's 42 for the collaborative. He's got flu shots at 79 percent, and they're at 60. . . .

"So you can see he's working really hard."

An Improvement in Scores

Independence Blue Cross announced in April that it would give all primary-care offices in its network a 10 percent boost in payments and offer $33 million to those that improve quality and become medical homes.

Those that perform best will be paid the most.

Richard Snyder, chief medical officer for Independence, called the collaborative's increases "fairly spectacular."

"Twenty-five percent more had control of their blood pressure after a year; 33 percent more had hemoglobin under 7 [which is good for blood sugar]; 43 percent more patients had [bad] LDL cholesterol below 130."

Mambu's practice had done well compared with others in Independence's vast network.

"Going from his 2008 to 2009 performance scores," Snyder said, "he went up 8.9 percent in one year, where the peer average went up 2.5 percent. And he's already starting at a higher rate than his peers. In other words, his effort is definitely noticeable.

"If you look at how satisfied his patients are, that's a similar story," Snyder said. "He had a 3.8 percent increase from 2008 to 2009, ending with almost 98 percent satisfaction."

The Start of a Network

Mambu has not reached the promised land, but he's close.

He sees what is possible.

He's forming a network with 15 regional practices certified as medical homes.

He gets excited as he talks about this. "What happens if these medical homes start networking, linking arms, strategically aligning with hospitals, labs, outpatient radiology, state agencies that are interested in information? Suppose we go to government and say, 'We're partnering and we want you to pay us differently?' "

He believes that in time these networks will contract directly with big employers and government to give medical care that will be cheaper and focus more on prevention.

The new health law provides billions of dollars and great discretion to the secretary of health and human services to promote the model around the country.

And Paul Grundy, director of health-care transformation at IBM, a leader of the TransforMED project, says the nation has already reached the tipping point. This will be the prevailing model of care, he said, and there's no going back.

Four hospital-owned practices at Abington, for example, will begin converting to medical homes within six months, chief operating officer Meg McGoldrick said. The hospital has asked Mambu to help.

Mambu says virtually all medical professionals will be forced to change in order to compete and survive.

One day soon, he says, it will come to pass. A doctor can dream.

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