Vermont tests team approach for aiding chronically ill

KEITH CHAMBERLIN/FLEK INC.After Rita Pinard’s blood sugar shot up, Dr. Joyce Dobbertin turned the patient over to a team, including a dietician and nurse, to help control her diabetes. KEITH CHAMBERLIN/FLEK INC.After Rita Pinard’s blood sugar shot up, Dr. Joyce Dobbertin turned the patient over to a team, including a dietician and nurse, to help control her diabetes. (Keith Chamberlin/Flek Inc.)
By Susan Brink
Kaiser Health News / September 6, 2009

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LYNDONVILLE, Vt. - When Rita Pinard learned she had diabetes three years ago, she didn’t imagine she would end up in an ambitious experiment that’s become part of the national health care debate.

Initially, she didn’t think her diagnosis was all that bad. Her physician, Dr. Joyce Dobbertin, “gave me a spiel about losing weight and exercising and told me to come back in three months,’’ says Pinard, 57, who promptly ignored the lifestyle advice.

But when her blood sugar shot up in January, her doctor took more aggressive action, turning her over to a nurse, a dietician, and a diabetes educator who nagged and encouraged her to try to control her disease.

The extra help is part of a state effort to improve care and reduce costs for the chronically ill in Vermont. Under the approach, primary care doctors get extra money to put together teams to treat people with illnesses such as diabetes, asthma, and heart disease. They get bonuses if their patients show progress.

This coordinated approach, called “medical homes,’’ is being tried in Pennsylvania, Wisconsin, Maryland, and other states, and Congress is considering adopting it nationwide as part of the health care overhaul being debated in Washington.

The House Democrats’ health bill calls for Medicare and Medicaid to conduct pilot programs for reimbursing medical home projects. The Senate Health, Education, Labor and Pensions Committee legislation would provide grants for community health teams that would support a medical home model.

The goal is to shift the health care system from emphasizing acute care for emergencies, such as heart attacks and strokes, to one focusing more on treating - or preventing - chronic illnesses.

The approach is showing promise. North Carolina, a pioneer in the area, and some other states say their efforts save money. Early data from the Vermont program, called Blueprint for Health, show diabetes patients are achieving slightly better control of their blood glucose levels after just one year, which could reduce costly complications.

Nevertheless, establishing medical homes on a national basis won’t be easy. For one thing, some specialists worry that giving more money to primary care doctors will eventually mean reduced payments for them, says Hoangmai H. Pham, senior health researcher at the Center for Studying Health System Change, a nonpartisan research organization in Washington.

There’s ample evidence that better treatment is needed for chronic diseases, which are responsible for seven of 10 deaths in the United States, and gobble up 75 percent of health care dollars, according to the Centers for Disease Control and Prevention.

When physicians diagnose a chronic disease, they often do little more than extol a healthier lifestyle, prescribe medicine, and tell patients to return in three months.

In Pinard’s case, her blood-sugar numbers stayed in the safe range for more than two years after diagnosis, and she remained sedentary and overweight. But when her blood sugar rose a few months ago, she was “devastated,’’ she says, and open to suggestions from a team that gave her advice on diet and exercise, nudging her via e-mails, and visits at home and in the clinic.

Shauna Brittell, a community health educator, gave her a walking program. Ginny Flanders, a registered dietician, gave her a glucose meter and told her it was best to eat carbohydrates early in the day.

“I couldn’t believe they had people like that who could sit and talk to me about what I needed,’’ Pinard says.

The medical home concept is being tested in two Vermont communities - rural St. Johnsbury, where Dobbertin works, and urban Burlington. Physicians are still paid under the traditional fee-for-service system, but get state grants to put together chronic-care teams that might include experts in nutrition, exercise, and behavioral health.

Providers get bonuses from insurers if the patients make progress according to national quality measures. “All providers in a practice have a stake in having a higher score,’’ says Dr. Craig Jones of the Vermont Department of Health.

Four additional communities are focusing on diabetes prevention as a first step toward becoming full-fledged medical homes. The goal is to expand the concept across the state.

The Vermont Blueprint for Health program began in 2003, and three years later became a part of the state’s comprehensive health overhaul, which is designed to ensure that 96 percent of residents have health insurance by 2010. In 2007, the state’s three major health insurers, Blue Cross-Blue Shield, MVP Health Care, and Cigna, were tapped to help pay for the program, whose funding last year totaled $4.8 million.

Since January, Pinard has lost 24 pounds, and most evenings walks three miles. “I didn’t go into this expecting people to cure me,’’ she says. “I know diabetes is mean to people. I don’t want to be babied. They’re part of my team, but I’m doing all the work.’’

This story was provided by Kaiser Health News, an editorially independent news service and a program of the Henry J. Kaiser Family Foundation, a nonpartisan health care policy research organization.