Doctors propose new health care model for at-risk elders


WILLISTON >> Vermonters want to grow older in their own homes, but programs such as Medicare won't pay doctors to visit their patients at home. That leads to a system where both doctors and patients are unhappy.

With few exceptions, Vermont doctors are paid when patients come into their offices, not when doctors make house calls. And ambulance crews that show up at someone's home get paid only if they need to take the patient to the hospital.

Those were conclusions from doctors involved in the Frail Elders Project through the Vermont Medical Society's Education and Research Foundation. They are encouraging leaders in health care reform to adopt new practices and change this phenomenon.

"Since the Nixon administration, we've done payment reform, and it doesn't do anything," said Dr. Cyrus Jordan from the foundation. "The cost just keeps going up."

Jordan and nearly a dozen others in the study group are suggesting the care delivery system be turned on its head. Instead of delivering care to seniors based on what programs like Medicare pay for, the group suggests paying for the care that seniors want and that will keep them healthy.

Dr. Fay Homan, a primary care physician who was a member of the study group, pointed to her patient who wanted to grow old and die in the farmhouse where she and her husband lived for years. Homan said the current system made it difficult for her team to care for the woman, even though she lived two doors down from the farmhouse.

Dr. Milt Fowler, another primary care doctor, said health care reform efforts in the last 15 years have made it hard to have face time with his patients. "There's 50/50 computer, face-to-face time where you really don't have any time to look at the subtle issues that are bubbling up with these seniors," he said.

"We don't have time for house-call visits," Fowler said. "You cannot believe how much more you get out of a visit one on one, in the home. Patients are not satisfied with the system, and certainly I'm not satisfied with the system."

As part of the Frail Elders Project, the group surveyed seniors with "complex health and psychosocial needs" who were at risk of seeing their health or quality of life decline. The seniors sought similar things when it came to their health care, the group found.

The seniors often said "independence, functional capacity, and deriving satisfaction and meaning from their daily activities" were important. Additionally, survey participants wanted financial security, social connection to friends and family, and to be "treated with respect and dignity" according to the study.

health care

As part of the study, the doctors point to two models for health care for seniors that they say Vermont could adopt: the Commonwealth Care Alliance in Massachusetts, and a federally funded program called Independence at Home.

Homan compared the idea of caring for frail seniors to concierge medicine, in which wealthy patients pay their doctors an annual fee to be on call 24 hours a day. She said frail seniors need a health care team that can be on call around the clock to assist them at home.

"We have an opportunity potentially if the all-payer model moves forward," said Dr. Josh Plavin, who led the study. He said government programs like Medicare could pay for bundles of services to patients and set the price based on the medical history of the population.

"Payment reform in and of itself is not enough," Plavin said. "If you actually change the delivery system you're shifting care from hospitals and the (emergency rooms) to the home."


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