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Forging efficiencies through medical coordination

In an economy fueled in large part by health care, innovations abound. There is robotic surgery, proton therapy, personalized genomics - even mobile-phone apps that are centered on medicine.

In an economy fueled in large part by health care, innovations abound. There is robotic surgery, proton therapy, personalized genomics - even mobile-phone apps that are centered on medicine.

Amid the whiz-bang, one set of innovations is considered so cutting edge that the federal government is spending $10 billion to research the best way to make it happen.

In this innovative model, doctors talk to patients, to each other, and to hospitals and laboratories, coordinating care and avoiding costly duplication of services.

It seems more like common sense than innovation, but because of the way health care is funded, it is not.

That is why longtime family-practice physician Richard Baron, 58, is now a federal bureaucrat working for the Centers for Medicare and Medicaid Services in Baltimore.

It's not that he's a burned-out doctor, it's just that he wants every patient to have the kind of care he tried to provide in his practice in Philadelphia's Mount Airy section.

"If I'm successful," he said, "patients will have a safer, smoother, and more satisfying experience when they interact with the [health-care] delivery system, and it will cost the country less than it does now."

Under the health-care overhaul act passed a year ago, the Centers for Medicare and Medicaid Services, a division of the U.S. Department of Health, received $10 billion to set up a Center for Medicare and Medicaid Innovation.

Baron is its "group director, seamless care models" - a title way more ponderous than doctor.

In March, Baron was a family physician, walking three blocks from his home in Mount Airy to his five-physician medical practice housed in a charming former greenhouse.

Now he is an Amtrak regular who sees his wife on weekends. "It was a difficult decision," he said.

"I took care of patients for 20, 25 years," he said. "To leave that to take a job with the federal government was not an obvious thing.

"What I found compelling is a pretty clear agenda within the agency that providers [doctors and hospitals] want to do the right thing," he said.

"We want to move from what we do now, which is rewarding volume, to figuring out ways to reward quality and get value. There are plenty of ways to lower costs without cutting care."

The federal government spends $850 billion a year providing care to the elderly, disabled, and poor through Medicare and Medicaid. Because the government is such a big spender, it sets the standard.

"If we find innovation and prove it, we can scale it up into the entire Medicare and Medicaid system," he said.

That's a big canvas for a physician who gained his satisfaction from acting like a small-town doc in a big-city neighborhood.

Under the current system, providers are paid by task. In a doctor's office, it's by visit. The more visits, the more money. Volume pays in pharmacies and labs and for services such as MRIs or X-rays.

Baron's role is to use technologies to coordinate the wholeness of patient care and reduce duplications in the care. If a patient is sent for an MRI, for example, but already had one taken fairly recently, there might not be a need for a second one, saving a good deal of money.

In 2004, Baron became an innovator in his field when his practice, Greenhouse Internists, installed an electronic medical-records system.

The computerized system allowed more coordination of care and, interestingly, allowed Baron to measure exactly how his doctors spent their days. He described the results in an article published in April 2010 in the prestigious New England Journal of Medicine.

In a sample week in 2008, the doctors averaged 18 visits a day - all billable. They also reviewed 35 laboratory, imaging, and consultation reports, filled a dozen prescriptions, handled 17 e-mails, and made 24 phone calls to patients and to other medical professionals.

Baron's practice participated in the Pennsylvania Chronic Care Initiative. In it, six insurers, including Independence Blue Cross, agreed to pay doctors more if they could improve diabetic care.

"Rich Baron was absolutely passionate that the resourcing be appropriate for the work we were demanding," said Don Liss, Blue Cross' vice president for clinical programs and policies.

"We can't provide a 6-foot rope to climb out of a 10-foot hole," Liss said, paraphrasing Baron.

As a doctor, Baron made the decisions in his practice. Working for the government "has been an interesting civics lesson," Baron said. "It's a team sport."

The team is working on "accountable care organizations," the official term for the coordinated and seamless care that Baron and others envision.

Baron has his own model of accountability - one that he experienced at the start of his career in rural Tennessee.

In a small town, "you see your patients in the grocery store. They teach your children. They work with your spouse. These folks came to me because of my expertise, but I relied on them for their special expertise."

One night he was paged to go to a nursing home to care for a dying elderly woman. A few weeks later, he needed something repaired and took it to a local shop.

"I said, 'What do I owe you?' " Baron recalled.

"He said, 'Nothing. You came to my great-grandmother's nursing home and took care of her.' "

Can Baron and his federal innovation center produce that kind of accountability?

Baron fervently hopes so.