New practice model could change game for providers

Change is coming to the nation’s primary care doctors, and specialists too. Some believe it’s the future of medicine. Others believe it’s what medicine always should have been, but for a dysfunctional fee-for-service reimbursement system.

The change is called the “patient-centered medical home,” and supply chain professionals whose IDNs have acquired physician practices will notice the change. No, you won’t find any flags outside physician practices’ doors signifying they are a patient-centered medical home, points out Andy Rice, Henry Schein U.S. medical training manager. But the concept is gaining significant traction across the entire spectrum, he adds. So be prepared.

The patient-centered medical home won’t look like the mom-and-pop medical practice of past years, says Bruce Bagley, MD, FAAFP, interim president and CEO of TransforMED, a subsidiary of the American Academy of Family Physicians. That doesn’t mean the patient-centered medical home has to be a big practice. But it will be more sophisticated than others. “Typically, practices that haven’t undergone any transformation lack a professional approach to the management of their finances, people and clinical quality – though that doesn’t mean they don’t take good care of their patients,” he says. But practices that have been recognized as patient-centered homes are more sophisticated organizations, in terms of leadership, decision-making and IT support, he says.

Physicians in such practices are no longer looking for medical devices, equipment, supplies, etc., that can help them generate revenue, continues Bagley. “The new conversation [with suppliers] is, ‘What can [the device’s] contribution be to the overall efficiency and effectiveness of the organization?’” he says. “Think of the accountable care organization. It has many different components – primary care, specialty care, IT – and each one of those components has to demonstrate its contribution to the effectiveness and efficiency of the enterprise.” In such a setting, the physician’s office might be viewed as a cost center, whose challenge is to keep costs under control while getting superior results in terms of patient care. “It’s a very different mindset,” says Bagley.

More focused approach
Since it was first introduced, the concept of the patient-centered medical home has evolved, according to experts. “It remains a solid construct about improving the patient-clinician relationship and the practice infrastructure to coordinate across the variety of needs a patient may have,” says Tricia Barrett, vice president of product development, National Committee for Quality Assurance, which, as of July 2013, had formally recognized 5,770 patient-centered medical homes. “I would say that there has been a shift toward proactive, population health management – away from episodic, illness-based care.” Patient-centered homes tend to adopt a team-based approach, rather than the doctor-knows-best approach.

Says Bagley, “If anything, [the concept of the patient-centered medical home] may have become more focused on a few critical areas. Initially, anyone could talk about anything they wanted; it was a concept that everybody could rally around. Since then, some of the more effective strategies have come into focus,” including team-based care, patient self-management and risk-stratified care management/care coordination.

“While the concept has not changed significantly for those who understand the depth of what is intended, the use of the term ‘patient-centered medical home’ itself may have lost some of its profoundness by those who don’t really understand the significance of the terminology,” says Allyson Gottsman, executive vice president, HealthTeamWorks, Lakewood, Colo., a 501(c)3 non-profit collaborative working to redesign the healthcare delivery system and promoted integrated communities of care.

“A particular example is the primary care physicians who are practicing in the traditional model but who say ‘I have been a medical home for years,’” she says. “When you ask someone if they give patient-centered care, everyone thinks that is what they have already been doing. There has been a real need for a ‘road map’ for doctors to follow so that they have specific steps to implement all of the [patient-centered-medical-home] components.”

Any and all sizes
Any practice – big or small – can be a patient-centered medical home.
“Whether a practice is large or small, urban or rural, if they have the right resources, they can implement systems to provide population management, care coordination, better access, and evidence-based care,” says Gottsman. “Continuous quality improvement can and should be provided in any primary care setting.” That said, she believes it is critical that practices aspiring to patient-centered-medical-home status make use of practice coaching to provide the accountability and guidance necessary for the redesign.

“Practices that have leadership, [and that are] knowledgeable and committed to medical home principles, are ideal,” says Peggy Reineking, director of clinical recognition programs, NCQA. “This requires a mental transformation on the part of the whole staff, so leadership is essential. This can occur at a practice of any size, including solo practices and practices with 80 sites.”

Adds Barrett, “I don’t believe there is a single ‘sweet spot’ for [the patient-centered medical home]. Our experience has shown us that practices of all types and sizes are capable of delivering this model and find a variety of benefits to doing so. It is true that the practice has to embrace the model as a team and that some individuals may not be willing to change their thinking and their approach to align with the new model. But that is about the individual – not the model or the size/type of practice.”

Not just the doctor
Empowered support teams are a surefire mark of the patient-centered medical home, according to experts.

“We have seen considerable variability in how practices take advantage of the skills, training, and education of mid-level providers,” says Gottsman. “I think it’s fair to say that in all cases, regardless of how they are utilized, mid-level providers have become an integral part of the patient-centered medical home.

“Some practices have chosen to use mid-level clinicians as complex case managers, working to support the complex patients and their families as they transition through various care settings,” she says. “We also see mid-levels helping to manage the complex comorbidities, empowering caregivers to manage the health of the patient.”

In some practices, mid-level professionals enhance access and make same-day appointments available for acute care, thus enabling physicians to be available to manage their panel of patients and provide better continuity of care, continues Gottsman. In another model, the mid-level clinician has a panel of patients whose health he or she manages. “This tends to be a smaller panel, but often includes some of the more challenging patients. In this model, the mid-level, working closely with the physician, is able to spend more time with each patient.
“When there is compensation for improved quality and lower costs, having less expensive mid-levels spend more time with complex patients is a good economic strategy.”

“The [patient-centered medical home] model encourages everyone in the practice to act at the top of their capabilities/license,” says Barrett. “I think the model empowers all individuals in the practice, and that includes mid-level providers. It is so much more motivating to be able to use your full range of skills; and by doing so it helps even out the work load for everyone.”

Effective strategies
Effective patient-centered medical homes practice:

  • Team-based care. In the patient-centered home, no longer is the physician considered the source of all knowledge, wisdom and decision-making. “In the past, we bundled [patients] from the front to the back of the office, put them in the exam room, and when the doctor walked in the door, the magic started,” says Bruce Bagley, MD, FAAFP, interim president and CEO of TransforMED, a subsidiary of the American Academy of Family Physicians. “That’s no longer OK. There’s so much more the team can do, such as patient education, patient self-management and between-visit follow-up. So it’s not just about doctoring, but about care. And it’s not the old concept of the multidisciplinary team, that is, a bunch of professionals who work on the same patient but don’t talk to each other. Now you talk about how to get the best results.”
  • Patient self-management. “We used to talk about ‘non-compliant patients,’” says Bagley. “Now we need to take responsibility for helping our patients have a role in caring for themselves. We talk about patient activation scores [to gauge a patient’s knowledge, skills and confidence to care for himself or herself], motivational interviewing, follow-up visits, home monitoring and patient coaching.”
  • Risk-stratified care management/care coordination. When Bagley talks about “risk,” he is referring to the risk that a patient can’t manage his or her way around the healthcare system, perhaps because of frailty, multiple chronic illnesses, or some other reason. “We need to figure out how to help them get the help they need,” he says. Today’s electronic medical records systems can help. “You need a point-of-care registry,” that is, a system that allows whomever is with the patient – regardless of physical location – to see the patient’s current status, gaps in care, care plan, caregivers, etc.

IDNs in the picture
What happens if a practice that operates as a patient-centered medical home is acquired by a hospital system? “It probably depends on the mindset of the hospital system and the reasons for the acquisition,” says Tricia Barrett, vice president of product development, National Committee for Quality Assurance. “They might bring a stronger supportive infrastructure and capital investment to provide better tools to deliver the [patient-centered medical home] model, or they might be simply looking for more sources of referrals, which could put the practice and the owner hospital at odds.”

Says Allyson Gottsman, executive vice president, HealthTeamWorks, “The literature suggests that hospital systems in general have not fully empowered acquired primary care practices to operate to the same extent as independent practices. One important consideration is that when you become a successful [patient-centered medical home], you are often very effective at reducing what amounts to the hospital’s top line revenue – emergency department visits and inpatient bed days. While we have seen enlightened hospital CEOs who are focused on moving to a delivery system that will thrive in a value-based compensation model, and excellent examples of robust support of PCMH by hospital systems, at the moment there is not a widespread acceptance by hospital CEOs.

The American Association of Family Practitioners says the patient-centered medical home “is a transition away from a model of symptom- and illness-based episodic care to a system of comprehensive coordinated primary care for children, youth and adults. Patient centeredness refers to an ongoing, active partnership with a personal primary care physician who leads a team of professionals dedicated to providing proactive, preventive and chronic care management through all stages of life. These personal physicians are responsible for the patient’s coordination of care across all health care systems facilitated by registries, information technology, health information exchanges, and other means to ensure patients receive care when and where they need it.

“With a commitment to continuous quality improvement, care teams utilize evidence-based medicine and clinical decision support tools that guide decision-making as well as ensure that patients and their families have the education and support to actively participate in their own care. Payment appropriately recognizes and incorporates the value of the care teams, non-direct patient care, and quality improvement provided in a patient-centered medical home.”