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The medical-home concept is already being tested in many markets for just this reason. In New Jersey, for example, AtlantiCare's pilot Special Care Center, a medical-home program collaborating with Atlantic City's largest hotel and restaurant union, is successfully reducing ER visits and hospital admissions. Two family physicians work with a nurse practitioner, and together the team discusses the best ways to treat those with chronic conditions such as diabetes and heart disease. Patients receive no claims forms or bills for services at the center, and salaried providers are not reimbursed on the basis of the volume of services they generate, so they can focus on providing appropriate, quality care. "The doctors and patients in the center are outside of what I call the tyranny of the visit," says Dr. Katherine Schneider, vice president of health engagement at AtlantiCare.
Making this shift on a national level, however, won't be easy. Even innovative health-system administrators acknowledge that as long as the fee-for-service reimbursement structure remains in place with private insurers, doctors will be forced to practice two kinds of medicine: one in which they are reimbursed on the basis of the volume of services they provide and another in which the health outcomes and efficiency of their care are prioritized. And as long as patients still view health care as an only-when-I'm-sick endeavor, costs will continue to rise. When Massachusetts subsidized health care coverage in 2006 and mandated universal coverage by 2007, visits to the state's emergency rooms swelled 7%, adding to a $146 million jump in health care costs from 2005 to 2006.
Massachusetts' experience highlights how much of our health behavior is ingrained in the current fee-for-service system — which, for the time being, isn't going away. The key to achieving real reform within the constraints of that reality will rest on persuading new — and existing — patients to seek care to maintain their health rather than to treat a disease after it has taken hold. If all goes according to plan, the bill's greatest achievement may be to make it possible for more people to access the health system in many different ways. Health care will increasingly take the form of preventive services such as regular diabetes checkups and weight-loss programs, instead of patients waiting to see their doctors until they need coronary-bypass operations or kidney dialysis. Those who are currently uninsured may turn out to be at the forefront of this trend, since 55% of them are under the age of 35, according to the Rand Corp. Traditionally, this group tends to be the healthiest segment of the population and uses health care the least. That makes it the ideal cohort to begin thinking of health care providers as wellness coaches rather than as emergency SWAT teams.