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Phil Kroll, 75, has grown accustomed to regular phone calls from his doctor’s office, the Anchor Bay Clinic Family Medical Center in Chesterfield Township.

“Nurse Angie calls me every three or four weeks, just to see how I’m doing,” Kroll said during a recent office visit. “She checks up on me, and I look forward to it because when I hear her voice it cheers me up.”

Calls to patients like Kroll are part of a trend in primary care, called the Patient-Centered Medical Home, that is transforming health care across the country. In Medical Homes, a physician-led care team continually monitors patients for health issues. The idea is to reduce health care costs by keeping patients healthy.

“I’ve found out if I got a problem, get it taken care of while it’s a minor problem and don’t let it get to be a big problem,” said Kroll, who has high blood pressure and has dealt with bowel, bladder and prostate issues.

Michigan is a leader in the Medical Home movement, due largely to the pioneering efforts of Blue Cross Blue Shield of Michigan, which has the largest program in the country to help primary care practices transform to Medical Homes. About 65 percent of the states primary care physicians — 4,534 doctors at 1,638 practices — participate in the program.

A study published earlier this year in the journal Health Services Research found that physician practices participating in the Michigan program reduced their patients’ use of emergency services 3.7 percent, and hospital visits 3.8 percent.

The reduction was three times greater for patients with six chronic health conditions that were closely monitored — asthma, angina, diabetes, chronic obstructive pulmonary disease, high blood pressure and congestive heart failure. Those patients experienced 11.2 percent fewer emergency visits and 13.9 fewer hospital stays, according to the study.

The study was based on three years of claims for adult patients in 2,218 physician practices statewide, and reviewed by the University of Michigan Medical School’s Institutional Review Board.

“The idea (is) to put the primary care physician at the center of care, in partnership with the patient, to improve quality, assure that care is accessible outside of normal business hours and coordinated between all providers that the patient might see,” said Marianne Udow-Phillips, executive director of the Center for Healthcare Research and Transformation at the University of Michigan.

“Blue Cross and Blue Shield of Michigan was at the forefront of this transformation, and has been a major catalyst for the expansion of the (Medical Home) model because it provided financial support and incentives for primary care physicians to develop the tools needed and reward improvements in quality and care coordination.”

It was largely because of the Blues’ efforts that Michigan was one of eight states chosen in 2010 by the federal Centers for Medicare and Medicaid Services (CMS) to participate in the Medical Home demonstration projects, Udow-Phillips added.

“Michigan’s version of that project, the Michigan Primary Care Transformation project, has been one of the most successful for Medicare, demonstrating savings from reductions in inpatient care,” she noted. “That work would not have been possible without BCBSM’s leadership, innovation and commitment.”

A number of other insurers and medical offices also have adopted the concept.

The model has been adopted by 75 percent of Michigan health centers represented by the Michigan Primary Care Association, said Jen Anderson, the group’s spokeswoman. The association represents 38 “federally qualified” health centers funded by the Health Resources and Services Administration, three certified by CMS that are not federally funded, and four Indian Health Services health centers.

“The patient centered medical homes are key to integrated care,” Anderson explained, “When you have your primary care, your behavioral health, your dentistry all under one roof, and everyone is working together to deliver patient-centered care.”

How to qualify

The practices must meet extensive requirements to receive the Blues’ Medical Home designation, and participation can bring financial rewards. Blue Cross helps pay the cost of converting to a Medical Home, and then reimburses the Medical Home practices at a higher rate based on their capabilities and quality of care.

To qualify for the designation, practices are evaluated on 145 capabilities in 13 categories that include such things as test-tracking and follow-up, electronic medical records and data reporting, as well as patient-friendly services like e-prescriptions, extended office hours and 24-hour access to a clinical decision-maker.

Medical Homes provide team-based care that includes case managers, dietitians and other personnel, and often belong to physician networks that provided shared access to medical professionals and administrative support.

Dr. David Share, senior vice president of value partnerships for Blue Cross Blue Shield of Michigan, offered this description of the program. “What we promise to you is to help identify your needs, and keep track of them, and reach out to you to give you the help you need in our office or coordinate care if you need to go elsewhere,” Share said. “And (we) help you be empowered to take care of yourself in the best way possible to stay healthy.”

The Anchor Bay Clinic belongs to a physician network, called Medical Network One, that provides the practice with the additional medical staff and administrative support required in a Medical Home setting.

“They provide us with a team of people,” said Dr. Karl Emerick, Kroll’s doctor at Anchor Bay. “We’ve got care management people who communicate (with patients) if they come out of the hospital, to follow up on certain things. We have a dietician who’s on site several days a week. We have a pharmacist who’s here several days a week, and we have a psychologist.”

Preventive maintenance

Nurse case manager Angie Siegmon calls Kroll regularly to see how he’s doing and help him focus on his health care goals.

“One of his long-term goals, he wanted to go out to California. He had family in California and he wanted to be healthy enough to make that trip,” Siegmon said, noting he achieved that goal and is planning another trip soon.

Kroll said his current long-term goal is to make it one year without going into the hospital.

“Preventive maintenance goes a long way,” he said, adding he thinks he’ll make it. “Help of the Lord, luck, keep taking my medicine and hope nothing crops up.”

kbouffard@detroitnews.com

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