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Ira Zunin, MD & Manakai O Malama: Integrative Medicine Model in a Patient Centered Medical Home PDF Print E-mail
Written by John Weeks   

Ira Zunin, MD & the Manakai O Malama Center: An Integrative Medicine Model in a Patient Centered Medical Home

Summary: Many in integrative medicine view the payment and delivery structure of the patient-centered medical home (PCMH) as exceptional for realizing an integrative medicine model. A leader, if not the leader, in implementing an integrative PCMH model is the Oahu-based Manakai O Malama Integrative Group and Rehabilitation Center led by Ira Zunin, MD, MPH, MBA. In this interview, Zunin describes the challenges and benefits of the new payment and electronic medical records initiatives his center has engaged in partnership with HMSA, Hawai'i's dominant insurer, and with the state's leading hospitals. Zunin, the sometimes consultant, offers his perspective on whether the 5-practitioner integrative clinic model proposed by Integrator adviser Bill Manahan, MD can work in the emerging PCMH environment.
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Other Integrator articles in the Integrator series on integrative medicine and the PCMH:

Integrator adviser Ira Zunin, MD, MPH, MBA distinguished himself early among integrative center operators for his business of medicine savvy. While developing his integrative clinic,
Manakai O Malama Integrative Group and Rehabilitation Center, he co-founded and for many years led the Hawai'i Consortium for Integrative Medicine. This unique organization included Hawai'i's top hospitals, health systems and insurers as members.

Ira Zunin, MD, MBA, MPH
Zunin's center subsequently partnered with
the state's dominant payer, Hawaii Medical Service Association (HMSA), a Blue cross-Blue Shield business, on a successful integrative medicine pilot project for high cost pain patients. Through it all, the 32-practitioner clinic has grown and thrived, according to Zunin. Meantime, under his Global Advisory Services hat, Zunin has consulted nationally and internationally on integrative medicine efforts. (Disclosure: Zunin and I have worked together from time to time.)

When Larry Rosen, MD and I began exploring our presentation
on integrative centers that are embracing the patient-centered medical home (PCMH) model for the 2012 Integrative Healthcare Symposium, I thought of Zunin. His clinic was already invested in an electronic medical record (EMR), a key PCMH component. From prior communication I knew he believed the PCMH could be a good model for integrative medicine. I called him to explore the subject. Is Manakai O Malama already operating as a PCMH or still planning on doing so? What changes does this demand? Where is the PCMH alignment with integrative medicine? Here is the interview with Zunin.
Note: Details about the Manakai O'Malama's model, types of practitioners, pre-PCMH revenue lines are available through the two articles noted above and via the Manakai O Malama website. The center has roughly 40 staff and has delivered over 250,000 integrative visits. Go to this site for a brief definition of the 5 characteristics of the Patient Centered Medical Home (PCMH) from the US Agency for Healthcare Research and Quality: comprehensive care; patient-centered; coordinated care; accessible services; and quality and safety.

Integrator: Let's jump right in. What do you think about the fit of the PCMH and integrative medicine?

: There are two sides to what makes the model attractive. One side is the standards for PCMHs and the approach to care. The other is the actual reimbursement model. Both make the PCMH conducive to an integrative approach.

Integrator: Start with the fit of the model.

Pioneering integrative PCMH
The cool thing is, PCMH is at its marrow integrative medicine. It's what we've always done. We've always done bio-psycho-social medicine. We (in integrative medicine) have never been just in the business of stamping out disease. The PCMH model is supposed to help the whole person, in his or her community. We've always been looking at everything with a bigger tool set, with a focus on health. We're oriented to this model. We're oriented to teams. So from that perspective, there's no change. But you do need to have some scale for this to work for you. It's hard for single providers. It is the most natural opportunity one can imagine for integrative medicine.

Integrator: So then, how do you believe the new payment structure works to support integrative medicine?

:  Well, first, there is a disincentive to not (moving into the PCMH structure). Those who ignore this direction get a frozen fee-for-service rate (here in Hawai'i). This is problematic in the future for those who just put their heads in the sand. Over time they will get fee-for-service rates that are more antiquated. Those who don't participate really are making a decision to think about retiring within 5-6 years. But if you are practicing longer, getting involved with the PCMH model makes sense.

Integrator: Well, that's quite a stick. Where is the positive side, the inducement?

   "As budgets sink in general and pressures
 hit on federal entitlement programs, it's made
a more closed, tight system. Fee-for-service
payments keep going down as they will here.
This erodes the paradigm of a payment per license
 or per diagnostic code or procedure code."

Zunin: As budgets sink in general and pressures hit on federal entitlement programs, we see a more closed, tight system. Fee-for-service payments keep going down as they will here. This erodes the paradigm of a payment per license or per diagnostic code or procedure code. In the PCMH, payment reflects more of the relationship with the patient and the outcomes. It plays into our hand. Things like integrative medicine, palliative medicine and conventional screening - all of their stock goes way up for these reasons. You have unassigned dollars that aren't directly connected to a provider or a procedure or a code. You can use the dollars from an integrative perspective.

Integrator: Let's drill this down a bit into how it will actually work with Manakai O Malama. What is the center's relationship with HMSA, the Hawai'ian Blues plan?

: The (PCMH) relationship kicked in officially in the last couple of months. They initiated us last quarter. Like I said, they begin by freezing fee-for-service payments at the current rate. They then start to give us a per member per month (PMPM) payment for each patient who signs up with our medical home. The basic amount you get paid PMPM is linked to how teched-out you are in your office, how meaningful your electronic medical record is. The entire payment plan is linked to other incentives.
There are three bases of payment you have in your PCMH. The second is pay for performance. This has to do with meaningful use of EMR. Examples are printing out after-visit summaries, or communicating online with patients, and billing electronically. This includes HEDIS outcomes like paps, mammograms, secondary prevention measures and patient satisfaction. Satisfaction is related to fundamental customer service like wait times and whether the patient felt the doctor listened. The third basis for payment is an annual fee based on total performance and whether we saved overall for the plan.

Integrator: Have you been paid along all 3 lines already? You seem confident this will work for you.

: We're in our first quarter so we don't know for sure yet.

Integrator: Is Manakai O Malama formally NCQA-certified as a PCMH?

: No. But we are essentially recognized as such by the local payers. 

Integrator: Your clinic has always treated a lot of chronic pain. How does this work in that environment?

 "In the PCMH payment reflects more of the
relationship with the patient and the outcomes.
It plays into our hand.
Things like integrative medicine,
palliative medicine and conventional screening -
all of their stock goes way up for these reasons."

Zunin: We like this system because we can de-link from the procedure. The team model lets us use our naturopathic doctors better. They are legally primary care providers in Hawai'i but the fee-for-service system here has not reimbursed them as such. I can use NDs more. There is more room for our Hawai'ian practitioners. They are legal but they are not typically reimbursed in fee-for-service. We can use them in this system. The structure also allows work with groups.  

Integrator: How do you foresee using groups in care.

: We just started another group for pain and depression and anxiety. We'll do more. We've always used groups with pain conditions. In this structure, I expect we'll do more with metabolic syndrome, coronary artery disease, obesity, sleep apnea. We have so many patients with diabetes. We have found our psychologist who has the lead in these groups is key with helping patients with their relationships with pain, with food, with any of their triggers.

Integrator: What's the role for massage therapist and acupuncturist?

: Massage therapy is key. You can't be successful without touching a patient. People need to be touched. Acupuncture will always be part of what we are doing here. It is such a fully developed, parallel track for care that encompasses the entire bio-psycho-social. It wouldn't feel like integrative care or doing what we set out to do with patients without acupuncture.
It's deep, powerful and indispensable for what we are doing.

Integrator: The transition in payment is huge. Day to day, are you thinking about care delivery differently? Have you educated your practitioner team around this? Are they embracing it and coming up with ideas?

: This year, the combination of our entire infrastructure investment, new software, hardware and electronic records has changed everything. So we have all been working on this transition. Integrative medicine requires continuous cultivation of the team. You don't just put something out there and let it go by itself. You have to keep a continuous focus on what you are trying to accomplish.

Integrator: You must use regular meetings.

Blues plan is the Center's payer partner
We have 2 lunch periods per month, one for admin issues and one focuses on clinical. Everybody in the clinic at the time goes. Usually there are 15-25 of us, of the 40 staff, which totals about 20 FTEs [full time employees]. We have also used 900 hours for the primary transition, the majority of these are training our staff in the software. Then we spent a great deal of time as a team looking at how we can function in integrative medicine with these new tools. EPIC is a very powerful EMR system, a lot of moving parts.

Integrator: The idea of engaging with an EMR or electronic health record is daunting and expensive-sounding for many.

: This was the year of infrastructure for us and the EMR was the biggest investment. There are hardware and software costs.
The software costs are greatest. These were much less than they might have been because when our main hospitals merged a few years ago, they all chose to be on the same EPIC EMR system. They offered community doctors a 70% discount if you join the EPIC community. There are only 3-5 clinics like ours here so we were a prime target. They invited us in as the 4th participating center. They got the system (for integrating a clinic) down before linking us which was good. We were the most complex because of the nature of our services and our provider mix. 

   "Integrative medicine requires continuous
cultivation of the team. You don't just put
something out there and let it go by itself.
You have to keep a continuous focus on
what you are trying to accomplish."

Integrator: Any special EMR challenges related to being an integrative practice? What was unique?

The hospitals gave us more development hours to enable every provider type to develop a unique screen for writing up case notes. The NDs can write in nutraceutical prescriptions, for instance. Our ND, who is also a PhD and a Rhodes scholar, manages a fairly robust formulary. The hospitals created unique referral screens for acupuncturists and for naturopaths. Let me clarify this. If you are inside the hospital, let's say someone has to refer to a cardiologist. They have a unique screen for this. Now the system has screens for referral massage, ref. acupuncture, ref. psychology, ref. naturopathy, ref. nutritional counseling. These also help with our own internal referral processes in the center.

Integrator: What was the cost and what are ongoing costs?

Zunin: We laid out a total of $125,000 in hard and soft costs with training and basically 3 month acute dip and 3 month sub-acute dip in volume, productivity and collections in the transition. We have a monthly payment of $2700 to maintain the system. The transition actually began 7 years ago when we were invited by 2 of the hospitals to participate with them electronically as a way to facilitate cross referrals. This has already paid off in a big way for us.

Integrator: So what evidence do you have that your practitioners like it?

First, no one has to look at charts any more. Second, any number of practitioners can view a patient's record at same time. We also have an in-basket intranet for discussing patients in HIPAA compliant format. Because we have exactly the same electronic footprint as Staub (Clinic & Hospital), right across the street from us, we've seen a tremendous number of referrals. It's kind of been a perfect storm. This came at a moment when we were already well-established. The culture is more open to integrative choices. Now it is so easy for other practitioners to communicate and see what we are doing here.

Integrator: The key money question: Is your center sharing the incentive payments with your acupuncturists, naturopathic doctors, psychologists, Hawai'ian healers and others?

: We haven't seen our first payment yet. Our arrangements with each provider is very different. It's case by case basis. 

Integrator: How did that early electronic linkage pay off?

 "If the form doesn't look like what they
are accustomed to, the practitioner wonders
about quality of care. It makes a huge
difference to be in the same system,
on the same forms."

Zunin: The ease of referrals coming in and the ability to communicate effectively with outside referring providers. If you have an electronic system inside your hospital or clinic, it is an effort to refer to someone outside the system. Since we joined the EPIC community, it's much easier for them to refer. A colleague once put it this way: If a physician or other provider is looking at a document that looks like you, that looks like documents they are familiar with, the doctor is fine with it. If the form doesn't look like what they are accustomed to, the practitioner wonders about quality of care. It makes a huge difference to be in the same system, on the same forms. 

Integrator: Given the costs, a clear directive to integrative practitioners interested in PCMHs seems to be to think about getting into a bigger clinic with other practitioners. Bill Manahan, MD, an Integrator adviser, recently shared his vision of "thousands of small clinics with about 5 caregivers from different disciplines working together to help patients heal." In Manahan's vision the caregivers will be "an MD/DO, an ND, some type of bodyworker, an energy worker, and body/mind psychology type of practitioner. Then there could also be Ayurvedic or Chinese Medicine practitioners as part of the group." Do you think such a team could work as a medical home?

  Regarding PCMH and the Manahan vision:

"The PCMH is more conducive to larger size.
I'd say that 10 practitioners would probably
do it. With just 5, it wouldn't be impossible
but you are really stretching.

Zunin: I'd say that it might work, but that this small of a scale would be a challenge in getting the work done. Really the PCMH is more conducive to a larger size clinic. In our center here, we could probably go down to 1/2 or quarter the size and have the PCMH still work. Ten practitioners would probably do it. With just 5, it wouldn't be impossible but you are really stretching. The number differs based on the mix. The more practitioners doing primary care and reimbursed for it, the fewer you need.

Integrator: So are you 100% in on this model going forward?

: No, the center still has its rehabilitative medicine side. That continues to be fee-for-service. We expect that before long the PCMH side will be not less than a third and not exceed two-thirds of our business.

Integrator: So what would your advice be for another center? Is holding onto rehab or some other fee for service line a safety move?

  "The fight is on for the soul of medicine.
Technology is just a tool. It can be incredibly
empowering. And without vigilance, technology
can absolutely rob the soul of medicine."

Zunin: Health care is in a time of major shifts and changes. The US healthcare system is a dangerous system to be in. I would recommend that any integrative clinic be as diverse as possible with its resource base, but without having too many moving parts. There is a tendency toward entropy in integrative centers. Integrative medicine is about juggling a lot of moving parts but keeping them moving in a therapeutic and viable direction. You can be too diffused. At the same time, if you get too focused in one area, one model, you can be on your rear in no time.

Integrator: Any last comments, inducements or red flags?

: There is a new set of environmental factors in the PCMH. For those clinics like ours moving forward into this model, we will be paying a lot more attention on how to leverage electronic medical records.
Don't get me wrong, there is nothing certain here. The fight is on for the soul of medicine. Technology is just a tool. It can be incredibly empowering. And without vigilance, technology can absolutely rob the soul of medicine.

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