Perspective: Florida medical home may offer a model for the future of senior healthcare

Jay Wolfson, DrPH, JD, is the Distinguished Service Professor of Public Health and Medicine and associate vice president for health law, policy, and safety at the University of South Florida (USF) in Tampa. He recently spoke with Medical Economics Editor-in-Chief Lois A. Bowers, MA, about an experimental Patient-Centered Medical Home and health law issues.

Q: You are co-principal and senior investigator for the USF Health–The Villages Health Status Survey and Health System Innovation. Tell me more about that project.

A: The Villages is such an exciting and extraordinary opportunity for all of us, nationally, as a model, because it is a large community of 100,000 seniors. It is owned by a single entity, and it is very well-organized and structured.

The owner/developer did not design a planned healthcare system, which is why he came to us and said, “Are you interested in partnering with us to build an innovative healthcare system with us that brings primary and specialty care together, that creates a medical care home, and that involves technology substantially in the management of patient care?”

Partnering with them is American Well, which is a virtual healthcare platform that presents some really cool telemedical interfaces, and we’re bringing our electronic medical information expertise into this community, which has a fabulous capacity to market, network, and implement very quickly.

Q: What kind of research are you conducting with this group?

A: We have started by talking to people in the community. We held dozens of focus groups for a year and a half that served as the basis of the survey that we conducted that was intended to establish a baseline of information about health status, health needs, and health behaviors in the community.

It’s not a Framingham study. We can’t go back and identify individuals. But we have 37,000 responses out of 91,000 surveys that were sent out. That is the largest percentage of responses of any survey at any time in the United States for an aging population, and the validity is just stunning.

Every month, we go there and hold seminars, and 800 to 1,200 people attend. We talk about orthopedics, diabetes, pulmonary diseases, electronic health records, and death and dying. They come out in droves. They tell us they want more involvement, interaction, information, and participation. They want to be wired in.

This is a very well-defined community, so we have the chance to demonstrate how a medical home system really works.

Q: What will be included in this Patient-Centered Medical Home (PCMH) model?

A: There are going to be eight primary care pods in this large community, along with surgery and specialty care centers, and everything is going to be interoperable and connected.

The first clinic is open. There are eight primary care doctors and three nurse practitioners, and we have pharmacists, health coaches, and physical therapists on site and in the community.

The second clinic is going to be open in March, and the other six will open in the next year. The specialty center is going to be open in March. That’s going to be staffed by the University of South Florida.

The physicians we are recruiting are being recruited exclusively for purposes of participating in the PCMH. So we tell them they are going to be providing care to patients, and the compensation, at least in the Villages, is likely to be higher than average community compensation because the idea is to attract the right doctors from wherever and let them do what they want to do most.

The idea of having a bona fide medical home, if you take it to its extreme, will include everything from soup to nuts, all the way to skilled care, home care, hospice care. When you look at the demographic dynamics of it, it is no different from the rest of the aging population of the United States. And there are lots of communities that are growing up to become like this, where they have comprehensive, coordinated, community-based functions that will be tied to healthcare. When you do that, you really create an operational medical home geographically approximate to the patient and all the specialties. And you make it more approximate when you have a functional health information capacity that literally brings communications capacity into the patients’ homes so they can talk to their physicians, they can talk to nurses, and they can be monitored electronically. It makes a big difference.

Q: What kind of feedback have you received from the residents so far?

A: We’ve learned that people like the idea a lot. They want to be able to have what a PCMH offers. They are standing in line and asking when the next center is going to open.

Unless you’ve been to the Villages, there’s no way I can explain it to you. It’s a big community that has multiple city centers. It’s kind of like Disney Celebration except that it’s for a senior population. They are very active people, and they are exceptionally health-conscious. All of the health indicators for them are well above the national average.

Q: What are their thoughts on the telemedicine aspect of the project?

A: For the populations that we’re seeing in the Villages, for instance, the aging population, they are asking for it. Not only for a more contiguous system of care, but they’re looking for things they can do in their homes. They don’t necessarily have to shuttle to their doctor’s office if they don’t have to, especially as they get older and lose their drivers’ licenses. It would be more convenient for them not to be in the hospital or nursing home but to be able to interface with their physician clinically, and the monitoring capabilities already exist.

Now that creates all kinds of confidentially questions. It creates all kinds of decision-point questions.

The technology is developing more rapidly than our use of it, so it’s kind of getting ahead of us, and there’s always the opportunity for misuse, but that’s where we going. And the question is, are physicians going to take control of this, or are they going to let the hospitals and insurance companies do it?

Q: You maintain a private practice as a health law attorney. What are the biggest issues you’re seeing in working with physicians or in health law in general right now?

A: Especially after the passage of the Affordable Care Act, there is a renewed emphasis on fraud and abuse. The federal government has begun hiring hundreds of attorneys, and in Florida alone I’ve seen this. For 7 or 8 years, there was almost an abatement of actions in fraud and abuse because the focus was on terrorism.

Physicians need to be attentive and concerned about all the fraud and abuse claims that can be raised and acknowledge the relationships they have with other physicians with other private parties. That’s where the feds are going.

Doctors have not been as good as they should be at office-based risk management. And it includes everything from fraud and abuse to the way they treat their staff, because we also see that the principal basis for fraud and abuse cases coming to the attention of the federal government is disgruntled staff members. Somebody wasn’t treated well, was terminated, was fired, got the short end of the stick.

What we’ve noticed in the studies I’ve done in the last almost 30 years is that when you have a recession economy and when you face a challenge of reductions in force, you automatically begin to see a tremendous increase in workers’ compensation claims, sexual harassment claims, other harassment claims, and fraud claims in physicians’ offices. It happens for two reasons. One, self preservation, and two, during these tough economic times, there’s a lot more tension in every work setting, so lots of personality issues play out. As much as a physician really just wants to practice medicine, she or he is the captain of the ship here.

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