Vt. health reform: manage chronically ill patients

SOUTH BURLINGTON, Vt. — What could play a central role reforming the nation’s health care system happens in a small conference room of the Aesculapius Medical Center — two patients learning the basics of managing their diabetes.

The pilot program begun in 2003 aims to reach patients with chronic conditions, keep them healthier and, ultimately, save money by heading off expensive hospitalizations and procedures. Already, emergency room visits are down.

It’s health care at its most basic, but in some ways it’s revolutionary. In a system where private insurers and the government reimburse providers for treating sick patients, the physicians who treat the two diabetes patients will get more if they stay healthy.

Almost 85 percent of Vermonters ages 65 and over have one chronic condition — such as diabetes, asthma or cardiovascular disease — and many have more than one. Treating chronic conditions accounts for 78 percent of health care spending in Vermont and 88 percent of all prescriptions. Experts say those figures are similar across the country.

Variations on Vermont’s Blueprint for Health are being used as a model in the national health care reform legislation now being considered by Congress, said Ken Thorpe of Emory University in Atlanta, who helped develop the Vermont program and is working with Congress on national reform.

The Vermont Legislature has passed a series of laws requiring the state’s three major health care players to reimburse the patients’ providers for their care. Plans call for expanding the project statewide by 2012.

At Aesculapius, registered nurse Pam Farnham goes over with the patients the best way to manage their diets and explains how diet and exercise can help minimize their symptoms and, hopefully, keep them healthier and out of the hospital.

“There’s a lot more that I learned here than I did when I was in the hospital,” said Peter Benoit, 62, of Colchester, who attended his first diabetes class recently at his South Burlington doctor’s office. “In this setting you understand more of what is going on and what you have to do to get yourself under control.”

The Blueprint allows physicians to spend more time with their patients, helps track their conditions and gives patients access to services they wouldn’t otherwise have taken advantage of. It also rewards physicians for keeping patients from getting sick.

“I think I am a better doctor because of this and I’m a more satisfied doctor because of this,” said Dr. Jennifer Gilwee, an internal medicine specialist at Aesculapius, named for the Roman god of medicine and healing. “This is in its infancy. It has real potential to really impact the demands on a primary care practice.”

The better a Blueprint provider does, the more it gets paid. The system uses statistics from the National Committee for Quality Assurance, a national nonprofit organization that measures health care performance.

Visitors from across the country regularly visit Aesculapius and a more rural practice in St. Johnsbury so they can see how it works up close.

The program is getting recognition from the federal government, too. Last month the Obama administration announced a new, three-year Medicare pilot program based on the Vermont program.

“This is the model for a delivery system redesign that has great potential for cost savings as well as the improvement for the health of the population of this country,” said Enrique Martinez-Vidal, vice president of Academy Health, a Washington organization that works to improve health care across the country. Earlier this year Martinez-Vidal brought delegations from five states to see Vermont’s efforts.

The Blueprint began in earnest in the Burlington area about a year ago. Since then, Fletcher Allen Health Care, which manages Aesculapius, has had more than 900 patient referrals and 2,000 patient visits to programs like the diabetes class, said Fletcher Allen Blueprint manager Randy Messier.

It’s still too early for hard data that proves its worth, but early results are encouraging.

“We are starting to see reductions in ER visits,” Messier said. “We’re doing follow-up phone calls for people discharged and we’re actually finding we are deferring some admissions.”

The Blueprint manages chronic disease through what’s called a “medical home,” a place where patients — no matter their health issues — have their care monitored. Information technology can be used to ensure, for example, that women get Pap smears or people get colonoscopies after they turn 50.

“Whatever level you’re at, you get good, high-quality medical care,” said Dr. Craig Jones, Vermont’s Blueprint director.

For those with chronic conditions, the Blueprint uses a “community care team,” of nurses, a health educator and a social worker. In some cases, patients are referred to the Greater Burlington YMCA, which provides two free sessions with a personal trainers and then donates a month’s membership, said YMCA CEO Mary Burns.

Most of the extra services don’t cost the patients anything, with most paid for through grants from the Vermont Department of Health, the state’s three major health insurance companies and Medicaid.

“The Blueprint is an important tool, one of the most important tools that’s in play right now in reducing costs,” said Kevin Goddard, a spokesman for Blue Cross Blue Shield of Vermont. “The financing makes sense to us, to go away from paying providers for every episode of care and paying for the totality of care.”