Here are three takeaways from an episode of Kentucky Health examining health care for senior citizens. Host Dr. Wayne Tuckson welcomes Dr. Misha Rhodes, chief medical officer for the nonprofit CenterWell system serving Louisville-area seniors.
1) Everyone as they age will develop ailments and face an increased risk of having a chronic disease. But the current health care model in America is not designed to treat an aging population, which results in poor quality of care and inefficiencies.
“The way I look at it now is primary care is a one-size-fits-all (model),” Dr. Rhodes says. While pediatrics has its own standards of care designed to treat children with frequent checkups, once a person reaches their mid-teens, he or she transitions into primary care and largely stays within that framework for the rest of the lifespan.
“It’s the same for everybody,” Rhodes says. “You get the same amount of time with your providers, you get the same issues addressed, and for the most part, it’s fairly transactional – when I’m sick, then I go in. There’s not a lot of preventative time spent to try to keep people healthy.”
Rhodes contends that an aging population needs more personalized care focused on the myriad concerns that every person will encounter during the last decades of life. She says the existing health care model should also devote more resources to preventive care and allocate more time for doctor-patient interaction during an appointment.
“For most traditional primary care practices these days, you may have 10- to 15-minute appointments,” she explains. “By the time you actually get into the room and see the patient, that time is cut even further short. And you hear patients say, ‘I really didn’t get a chance to talk about what I wanted to talk about.’”
At the core of our current health care system and how it operates is what is known as fee-for-service, Rhodes says. That’s where patients schedule appointments with providers to address a particular health issue – be it a case of flu, a broken wrist, or something else – and then pay for treatment of that problem. Aside from an annual physical, patients rarely engage their primary care doctors or nurses with any other request.
“It’s a transactional relationship,” Rhodes concludes. She believes that fee-for-service drives primary care providers to see as many patients as possible to generate profits in their practice, rather than spend more time with each patient and implement a more comprehensive and individualized approach.
In recent years, a model called concierge care has grown in popularity among patients who can afford to access it. With concierge care, patients “buy-up” services beyond their Medicare or insurance limits and receive longer appointment times, on-call services, and other privileges. Rhodes acknowledges the benefits of concierge care for wealthy seniors, but she believes they should be made available to everyone.
2) Shifting toward a “value-based” health care model will help senior patients improve their overall wellness and catch more ailments in early stages.
This value-based model focuses outcomes, Rhodes explains. “Fee-for-service is about, ‘How many patients can I see in a day to be able to meet my quotas or business needs,’ and with value-based care, it’s about what’s the actual quality? Are we having the outcomes we need to have? Are we keeping patients out of the hospital? Are we keeping them healthy? And are they staying at home and having a better quality of life?”
Instead of relying on fee-for-service payments, the value-based model compensation structure rewards providers for meeting certain metrics of wellbeing for each patient. “At the end of the day, if patients do well and you’re able to address the evidence-based measures that we know affect quality outcomes, then you are rewarded for that,” Rhodes says.
Patients who enroll in a value-based model encounter “a little bit of a mind-shift,” Rhodes says. “A lot of patients are used to, ‘I come in only when I’m sick,’ and what we are educating patients on is that we want to see you more frequently. We don’t just want to see you when you’re sick, because by the time you are sick, we may be too far behind to really make an impact.”
Rhodes concedes that medical providers used to a fee-for-service basis also have a period of adjustment when shifting to a value-based model. One significant change concerns documentation, she says. Rhodes recalls her own medical training and how most primary care physicians came to rely on a fast and sometimes abbreviated process of note-taking when seeing a large number of patients. Under the value-based model, she says providers are asked to write longer, more detailed notes about each patient and visit.
“It doesn’t have to be three pages of notes, but to document specifically how well or how ill your patient is,” Rhodes explains. “I like to say it’s telling the patient’s story.”
3) The CenterWell model offers a health care paradigm that results in better patient outcomes and potentially can be scaled up.
The health care model at CenterWell is value-based, Rhodes says. It operates in 15 states across the U.S., and the three Louisville branches are open to any senior citizen in the metro area (including southern Indiana) with Medicare. She adds that persons under age 65 who are on Medicare can also use CenterWell, and there are no restrictions on pre-existing conditions.
The facility houses an entire team of medical professionals to provide comprehensive care for patients, Rhodes explains. “For our team within primary care, we have our physician, our nurse practitioner. Within the center, patients will have support from a social worker, behavioral health specialist. We’ll have a registered nurse that helps do a lot of patient education around chronic diseases, and then of course we have our wonderful medical assistants and front office staff and administrators,” she says.
In addition, Rhodes says doctors at CenterWell will refer patients to outside specialists for care when warranted and also provide transportation to those appointments. That’s critical for many patients who may not have the physical ability to drive or the financial means to secure a ride.
“We try not to let those social determinants of health be a barrier to someone’s health outcomes,” she says.
The model at CenterWell aims to provide comprehensive care for each senior patient, and Rhodes says their primary care physicians are trained to treat most diseases. If a referral to an outside provider is needed, the staff at CenterWell will schedule one – and they are not limited to any specific health care network when doing so.
Using this value-based model, Rhodes says physicians and nurse practitioners treat around 700 to 750 patients at CenterWell. The time allotted for office visits ranges from 45 to 60 minutes for an initial visit and 30 minutes for follow-ups. She says these visits are scheduled based on each individual’s health care needs. Relatively healthy patients may visit two to four times per year, while those with chronic diseases will visit more often.
Rhodes recalls a Louisville radio host who, after learning about CenterWell, labeled its model “Oprah-level care.” She agrees with that description and says she hopes the value-based model will expand in the future to serve more adults under age 65 who are not on Medicare.
“Seniors deserve to have great care,” she concludes. “You deserve to be treated like family when you come in the door, and you deserve to have time for someone to listen to you.”