By Ulfat Shaikh, MD
“My friend was a neurologist at a hospital in New Orleans”, my daughter’s art teacher told me when we were chatting at pick-up time about my upcoming trip to New Orleans. “She lost her home in Katrina”, she continued. “The stories she told me about how they cared for all these patients in the hospital with no electricity and water and barely any resources were just plain scary”.
My last trip to New Orleans, Louisiana, was in 2003, two years before Hurricane Katrina. My personal agenda for the trip included crawfish, shrimp po’ boys and café au lait. Now, more than a decade later, I am back and the city looks vibrant, though still recovering from Katrina’s onslaught. My personal agenda during this trip includes learning how a health system was resurrected after near-complete destruction and if this metamorphosis was sustained.
Imagine you were charged with redesigning a health care system. Say, your resources were not exactly limitless. And by the way, your health care system served a disproportionally large number of impoverished and marginalized patients. This is what those of us who work in quality improvement in safety net hospitals seem to face every day. But in relation to what clinicians and hospital leaders faced ten years ago in New Orleans, our job seems in comparison, undemanding.
So what lessons does Hurricane Katrina teach us about rebuilding a health care system from the ground up?
In its pre-Katrina days, New Orleans was much like many other large cities in the US. A large proportion of its residents relied on emergency rooms for their medical care. The most deeply affected were the uninsured, who make up one-fifth of the city’s population.
In little more than eight years, New Orleans reconstructed its healthcare infrastructure through a focus on transforming safety net clinics into medical homes that provided multidisciplinary team-based care. An emphasis was placed on implementing electronic health records as soon as possible. Emergency preparedness was, of course, a priority. Since patients now had medical homes, community clinics could more readily identify those at highest risk during power outages or natural disasters. Community clinics in New Orleans received substantial bonus payments for attaining nationally recognized medical home standards and many were considerably successful in enhancing access, quality, safety, care coordination, and integration.
A major issue, however, was significant variation in the progress that clinics made and the worrisome fact that many practice changes were stalled once federal funding dried up. In clinics that implemented medical homes, a key barrier to sustaining change was an unstable financial support system.
A JAMA article published the week I returned home from New Orleans spoke to the yet unfulfilled promises of medical homes. The authors studied a three-year pilot of thirty-two primary care practices in Pennsylvania. Practices introduced structural capabilities such as disease registries and electronic medication prescribing. They received expert assistance and incentive payments for achieving patient-centered medical home recognition by the National Committee for Quality Assurance (NCQA). Over three years, practices received bonuses averaging $92,000 per primary care physician.
The study showed lackluster improvements in quality and no reductions in healthcare utilization or cost of care. The authors noted that practices were not incentivized to reduce costs or utilization of care, which might have partially resulted in these findings. The NCQA responded by stating that practices in this study used older standards, which have since then undergone a couple of revisions.
A lesson learnt from this experience is that medical homes need to have an increased emphasis on patient outcomes, and not be overly focused on structural and process measures. Medical homes should be a means to an end rather than an end in themselves.
A contrasting report released around the same time noted that medical homes in Minnesota showed improved quality of care, especially for chronic diseases, and resulted in costs savings.
As the New Orleans, Pennsylvania and Minnesota experiences indicate, the road to primary care transformation remains long and steep, with suboptimal visibility. A major pain point is lack of consistent evidence regarding the effectiveness and sustainability of interventions, particularly if financial incentives are poorly aligned. In quality improvement, context is king. Patients may be better served by moving finite energy and resources away from scrambling to achieve blanket and overly general medical home requirements, and instead focusing on customized interventions for populations with chronic diseases and unique social determinants of health.
-Ulfat Shaikh, MD, MPH, MS is director of health care quality at the University of California Davis School of Medicine. She blogs about health care quality improvement at Pulse.