CHI Health Care: Trials and Tribulations at the Nation’s Model Integrative Medicine Medical Home

On the surface of things, the values of “accountable care” and “patient-centered medical homes (PCMH)” and those of integrative medicine suggest a convergence. A survey found alignment in integrative medicine leaders. Maryland integrative doctors David Fogel, MD, and his spouse Ilana Bar-Levav, MD, presented with a substantial philanthropic gift, jumped into the apparently convergent rivers with both feet, creating the interprofessionally rich environment that is now CHI Health Care. The goal was and remains to prove the value proposition of integrative medicine in the medical industry’s move from volume to value. The center gained recognition as a PCMH and became part of a Medicare Shared Savings accountable care organization (ACO). Now Fogel makes clear that the convergence of the two paradigms have produced rumblings of boulders at the river bottom. While he remains positive about the model, the systemic obstacles are daunting.

CHI Health Care – which began as the Casey Health Institute – drew a visit from a US Surgeon General when they reported early cost and health outcomes that significantly outperformed conventional practice metrics.  Their outcomes were built on investing in, developing and modeling a high-performing, collaborative, interprofessional team of medical doctors, naturopathic doctors, nurses, acupuncturists, chiropractors, yoga therapists, psychologists and others. With both feet planted in the value-based world – as a CareFirst Blue Cross Blue Shield PCMH and as a member of the Aledade ACO, they continued to pioneer the convergence of payment reform with integrative primary care. In my late 2015 posting on the these actions,  I concluded with this comment:

The bet from [the CHI team] is that when the data comes in, the case for integrative primary care will be made. Like a veteran betting person at the track, I’ve done my analysis of the racing form. I’ve a good feeling for this horse. Better yet, for a bettor: I know the trainer – Fogel, and many on his team – and have an idea through this series of interviews about how well the horse is being cared for and handled. I like, for instance, [that they have] administrators whose work is grounded in clinical understanding. Still, it’s a little nerve wracking.

I recently connected with Fogel to prepare for a panel presentation at the February 2019 Integrative Health Symposium that will include his report plus that of Mark Hyman, MD on the Cleveland Clinic Center for Functional Medicine and Lorilee Schoenbeck, ND on her pioneering work as a naturopathic PCMH. The interview did nothing to abate my nervousness. Here are quick, overlapping take-homes.

  • Misfit #1: Size Requirements for PCMH  CareFirst sets rules both for how many patients and how many primary care doctors an administrative unit needs in order to qualify as a PCMH. With 6,000 patients and its mixed, integrative practitioner make-up, CHI Health Care could not meet the current standard on its own.
  • Misfit #2: To Meet Size Requirements, Outcomes Lost Their Distinctive Integrative Character To meet requirements, CHI Health care was paired with a stand-alone clinic that was neither part of the CHI Health Care’s integrative culture nor did it reflect the referral patterns that led to the outcomes that grabbed the Surgeon General’s attention. The data no longer reflected their model alone.
  • Misfit #3: No Bargaining Power as a Start-up Fogel notes that CareFirst can “move the goal post” whenever it wants while CHI – as a start-up that is a relatively small business unit – lacks both bargaining power and the the resources to respond rapidly to whatever changes CareFirst chooses to dictate in the playing field.
  • Misfit #4: Investment in EMR and Other Systems Tough for a Small Unit The sheer investment in systems and in time costs to continuously participate in both the PCMH and the ACO each favor larger businesses. Says Fogel:  “It’s virtually impossible to work in the value-based world as a relatively small entity. You need economies of scale.”
  • Misfit #5: Outcomes Data Buried in the Larger System Although Fogel notes that “there are rationales for working with larger units in the greater scheme of health care reform, CHI Health Care’s integrative data no longer could be judged, or paid, on its own results.”
  • Misfit #6: Bonus Payments Needed for Business Model Not Awarded The Center could not get hundreds of thousands of dollars of anticipated bonus payments because its outcomes were rolled together into the larger pool. “Our data gets diluted,” explains Fogel. CHI is in negotiations with Care First still to recover what it believes it is owed. They’ve been waiting 8 months for a decision. Fogel is blunt: “There are incompatibilities between our business model and the often changing requirements of the ACO and PCMH systems in which we are working.”

My assessment was less friendly:

CareFirst’s actions sounded to me like the Lily Tomlin skit on the phone company in which the refrain is “we don’t care because we don’t have to.” I thought of the recent rather frightening Atul Gawande article in the New Yorker, “Why Doctors Hate Their Computers”, in which he portrays the struggle between humans and machines – and the balance tends toward the latter.  I thought of UK author Ernst Schumacher’s compelling, plaintive cry against globalization in Small is Beautiful: A Study of Economics as if People Mattered. I remembered Bambi meeting Godzilla. I recalled the Star Trek line: “We are the Borg. Resistance is futile.”

Bottom line: the emerging version of the medical industry may consider itself value-based but it lacks receptivity and adaptability for the value of innovation that a smaller unit can offer. In the case of CHI Health Care it is throttling the chances of this integrative model to have a chance to grow, flourish and be seen as a method for humanizing health care while also generating remarkable outcomes.

Fogel is not negative: “Our model has gotten the attention of some forward looking leaders in both regional health systems and major insurance companies.” He notes that increasing awareness of the value of non-pharmacologic approaches amidst the opioid mess has led to interest in CHI Health Care as a potential integrative pain partner. Interest has not yet transformed into action. He’s also speaking with a physician owned company involved with direct primary care to explore opportunities to pioneer an integrative direct primary care model. He is sold on the value the CHI’s naturopathic doctor Sandra Colvard, ND and of naturopathic doctors in general as coordinators of services in interprofessional, integrative settings: “She adds a solidity and a wisdom.” And after some glitches with the center’s electronic records systems, CHI Health Care’s patient satisfaction numbers “are consistently in the mid-ninetieth percentiles.” He explains: “Now that we’re worked out some electronic problems that were harming patient experience, our patient satisfaction is fantastic.”

Still, Fogel increasingly believes CHI Health Care’s big play is to find a large institutional partner on the delivery side. He notes the irony that if the Center was, for instance, to become part of a hospital system, their ability to bill could double or triple, with facility fees and other benefits that go to hospitals and major delivery organizations.

Fogel remains optimistic about the integrative model he is seeking to prove: “I believe 150% that if you start with less invasive, natural approaches first, you’ll have better outcomes at lower cost. Add to this optimized care coordination and interprofessional collaboration in a value based model and you’ve got a turbocharged health care.  I’m not disillusioned – there may be a silver lining.” He pauses: “With economies of scale, bargaining power, and a platform of support, we just might have a chance to take integrative primary care mainstream.”