To most people, medical advances mean new drugs or high-tech gadgets to diagnose and treat

illnesses.

But one of the biggest changes is coming from the physicians who provide basic care &#8212

family medicine docs and internists.

In Buffalo and elsewhere, a radical experiment has begun at hundreds of medical practices

that could transform medicine, improving quality, controlling costs and leaving patients more

satisfied.

The pioneers of this new concept, call the &#8220patient-centered medical home,&#8221 hope

to shake up a profession that is in crisis.

The physicians embracing the concept are installing computers that can track tests and

identify patients at risk of serious problems.

They are turning patients with complex illnesses over to a team of nurses, pharmacists and

physician assistants to coach them about self-care and follow up after visits.

They are using guidelines to base decisions on the latest scientific evidence and measuring

their quality.

They&#8217re also making themselves more accessible. Patients can arrange same-day

appointments and talk to someone during off hours.

&#8220We&#8217ve got to change. There are more patients today and less time to see

them,&#8221 said Dr. David Pawlowski, one of six physicians at the Highgate Medical Group,

which has embraced the effort.

Primary care organizations representing 330,000 doctors agreed on patient-centered medical

home principles in 2007.

Anthony Antonik&#8217s story shows the potential power of the medical home.

Buffalo Medical Group, which has embraced the medical home philosophy, wanted to use its

electronic medical record system to identify patients with potential health problems, starting

with a condition known as an abdominal aortic aneurysm.

Problem often fatal

This is a bulge that grows with few noticeable symptoms in the body&#8217s main blood

vessel and, if left untreated until it ruptures, is generally fatal. lethal.

Buffalo Medical Group&#8217s computer, after searching hundreds of thousands of records,

spit out the names of more than 2,000 patients at higher risk for the aneurysm. Tests found

30, including Antonik of Orchard Park, with aneurysms that could burst at any moment.

&#8220I was on the verge of death,&#8221 said Antonik, who underwent surgery last summer.

There is good reason for such changes. Primary care in the United States is in trouble.

Most medical students are choosing higher-paying subspecialties instead of primary care. The

number of U.S. medical school graduates choosing family medicine as a specialty has declined

from 2,340 in 1997 to 1,083 in 2009.

Meanwhile, as the elderly population increases, the number of patients with chronic

conditions is on the rise, as is the cost of treating them.

Patients with complex illnesses see multiple doctors and take a confusing mix of

prescriptions.

These patients need coordinated care, yet often don&#8217t get it from a fee-for-service

system that rewards quantity of care over quality, experts say. All of which leads to unneeded

emergency room visits and hospitalizations, overuse of tests and procedures, and sick patients

returning to the hospital soon after being discharged.

Advocates see the medical home concept as the best alternative.

&#8220It&#8217s a chance to reinvigorate the specialty. The hope is that the medical home

will result in better outcomes, reduced hospitalizations and less misuse of care,&#8221 said

Dr. Thomas Foels, chief medical officer at Independent Health.

Collaboration

Independent Health is collaborating with 22 urban, suburban and rural offices, including

Highgate Medical, on a two-year medical home pilot project that began in early 2009.

In this effort, the largest in the area, the health insurer plays a key role, providing the

doctors with patient data, coordinating some care, operating a phone center to shorten wait

times, and offering health coaches and case managers to help patients take care of themselves

at home.

&#8220I feel like the quarterback of a team,&#8221 Pawlowski said.

Others involved in the medical home movement include the Catholic Independent Practice

Association, the group that represents the more than 800 doctors affiliated with the Catholic

Health system.

Buffalo Medical Group is incorporating the principles of a medical home at its six primary

care locations. The physician association is working with six of its 80 primary care practices

and hopes to add six more to the effort this year.

Dr. Michael Edbauer, the association&#8217s vice president of medical affairs, likens the

transformation to retooling an automobile assembly line.

&#8220It&#8217s an investment in the primary care infrastructure,&#8221 he said.

The Buffalo Medical Group&#8217s Williamsville medical office, along with more than 220

sites nationwide, have met the criteria for the highest level of recognition for medical home

care established by the National Committee for Quality Assurance, an accrediting and

standards-setting organization.

Among other changes, Buffalo Medical Group invested in new technology, including an

electronic medical record system that can track diseases and an Internet Web site that gives

patients access to health records and lab results, and allows them to make appointments and

get questions answered.

Sharing results

&#8220Everyone has been trained to work with

patients one-on-one. Now, we&#8217re using a team, and we measure the outcomes, and we share

those results among ourselves. That&#8217s a big change,&#8221 said Dr. John Notaro, associate

medical director for the group and a primary care physician at its Orchard Park office.

The medical home concept wouldn&#8217t work without changing the way the physicians are

paid a set amount regardless of how much time they spend with a patient.

In addition to visit-based fees, Independent Health, for instance, offers monthly care

coordination payments and annual bonus payments for reaching quality milestones, such as

reduced hospitalizations.

&#8220The fee-for-service system is about driving up the volume of visits, and revenue

depends on moving patients through the office. It is antithetical to the medical home,&#8221

said Foels.

Buffalo Medical Group and Catholic physician association are receiving some support from

health insurers. But their expectation is that the investments they make now will lead to

higher payments later.

&#8220As we work through the reimbursement issues, there is going to be more agreement

among physicians about the philosophy,&#8221 said Edbauer.

Not everyone shares the enthusiasm for medical homes.

Critics say few organizations have the financial and technical wherewithal to do it well.

They also wonder if the concept is nothing more than a repackaging of managed care, bristle

at the suggestion that doctors need financial incentives to do the right thing, and view the

focus on efficiency as more appropriate for a factory.

&#8220As we move to more efficient, industrialized medicine, the already frayed connection

between doctor and patient, critical for the chronically ill, may weaken further,&#8221

physician and health policy analyst Dr. Caroline Poplin wrote last year in the journal Health

Affairs.

Even advocates voice skepticism.

A recent review of medical home projects in the Annals of Family Medicine, although

supportive, noted that the transformation required &#8220epic whole-practice

reimagination&#8221 that, if done poorly, could jeopardize the entire endeavor.