Reinventing Primary Care
Cover Story — November 2014
Tex Med. 2014;110(11):26-34.
By Amy Lynn Sorrel
Patients of Village Health Partners in Plano may not know they are walking into a carefully constructed medical home. But founder and family physician Christopher Crow, MD, wants them to feel at home.
Before patients even arrive for their appointments, the family practice calls to remind them of any upcoming preventive screenings due at the same time, like mammograms or blood sugar tests. If patients call or show up to the family practice at five o'clock in the evening, they aren't greeted by an answering service or a "Sorry, we're closed" sign. And should they end up in the hospital or emergency department, a care coordinator gets a notification the same day to check in and keep tabs on any medications prescribed or any specialized follow-up.
Under one roof, patients find the comforts of personalized primary care. Physicians count on a team of medical professionals practicing at the top of their licenses. And ideally, over time, everyone reaps the rewards of healthier results and lower medical costs.
Granted, it took several years of do-it-yourself work for Village Health Partners to lay the groundwork for the sophisticated structure and eventually attract investors, in this case, payers, says Dr. Crow, past chair of TMA's Council on Socioeconomics. The home improvements continue, too.
"Most of my colleagues would agree this is the way we wish we could care for patients. The problem is, the financing is not directly linked to the activity," he said, referring to the slow shift from fee-for-service payments to value-based payments that reward doctors for improving quality and cost of care.
Finding the Way Home
Dwindling health care resources and budgets are turning the patient-centered medical home into a hot commodity for making health care more efficient and effective and less fragmented and costly. They start with a solid foundation: primary care.
Whether the enhanced primary care model lives up to its promise is still up for debate, based on the available research. Still, policymakers, payers, and physician practices are increasingly taking the bet, particularly with passage of the Affordable Care Act. Recent Texas legislation also encourages medical home development, particularly within Medicaid.
The Texas Medical Association supports use of the model across payers, and patients most likely to immediately benefit are those managing chronic conditions. TMA recently formed a committee dedicated to exploring medical homes as a component of access to care and finding a "Texas way" to make the model more accessible for the multitude of practices — big and small — that dot the Lone Star landscape.
TMA's Healthy Vision 2020 calls for the use of the patient-centered medical home (PCMH) model in Medicare, Texas Medicaid, and commercial insurance plans. "Given the budget constraints Texas faces and a growing population with unique health care needs, the PCMH offers the potential for Medicaid cost savings as well as improved patient outcomes and physician and provider satisfaction," the document states.
Meanwhile, the American College of Obstetricians and Gynecologists is leading a collaborative practice task force composed of the various primary care disciplines, including allied health professionals, to develop multidisciplinary, team-based care models like the medical home that work for various patient populations and geographic areas.
The National Committee for Quality Assurance (NCQA), for example, recognizes nearly 400 medical homes in Texas, but TMA leaders worry the intensive certification process may not be feasible for small practices.
Public and private insurers across Texas are running several pilots, but physicians say payers will have to up the ante on their commitment to promote widespread adoption of the resource-intensive model. For now, some insurers seem to need more convincing, as emerging data show mixed results on the relatively young concept.
Dallas internist Sue Bornstein, MD, chairs TMA's newly created Committee on Primary Care and Medical Home and serves as executive director of the Texas Medical Home Initiative. With TMA's help, the initiative led a statewide pilot in 2011 to help a select group of Texas practices of various shapes and sizes start the transformation process into PCMHs.
On the one hand, she agrees further testing is necessary to figure out which of the many different practice capabilities involved — care coordination, population management, enhanced access to care — will have the greatest impact on health outcomes.
On the other hand, "the evidence is pretty clear that an engaged patient is one who is going to do better" in terms of his or her health, Dr. Bornstein said. PCMHs are helping reinvent primary care and show "how important and central it is to a well-functioning health system. But until we get a champion at the state level, we are going to be doing this piecemeal."
Because every primary care practice and its patient population are different, no single pitch makes for a medical home run. But experts do agree on a defined set of principles. The main attributes of a medical home require health care delivery to be:
- Accessible, and
- Committed to quality and safety.
The four major primary care physician associations — the American Academy of Family Physicians, the American Academy of Pediatrics, the American College of Physicians, and the American Osteopathic Association — formalized the medical home concept in a set of "Joint Principles of the Patient-Centered Medical Home" in 2007.
The principles have since won endorsement from the American Medical Association and more than a dozen other physician organizations, as well as the national Patient-Centered Primary Care Collaborative. Alongside sprung up a number of medical home recognition or accreditation programs that quality oversight organizations such as NCQA, the Agency for Healthcare Research and Quality, and The Joint Commission developed based on the joint principles.
NCQA Assistant Vice President of Recognition Programs Mina Harkins says the organization's medical home certification helps practices demonstrate an objective set of standards, while assuring patients and payers that those standards are being met.
While some practices have benefitted from formal recognition, Dr. Bornstein clarifies such accreditation is not needed to become a medical home, nor do all payers require it. The process can be time-consuming and costly, especially for smaller practices, when many may already be doing activities considered part of a medical home they can build on, she adds.
Keller family physician Gregory M. Fuller, MD, says that's how North Hills Family Medicine got started before it went on to pursue NCQA recognition in 2011 as part of the statewide pilot. The five-physician practice had already begun actively monitoring certain quality measures via federal initiatives like the Physician Quality Reporting System and meaningful use of electronic health records.
North Hills used the medical home transformation process to formalize those quality measurement processes and to use the data to get a better handle on how well patients' diabetes or heart conditions were under control, reconcile patients' medications, and identify and close other gaps in care. The practice also slowly started extending office hours at its two clinic sites to nights and weekends so patients have more convenient access to the regular care they need to manage their conditions.
One of the first steps toward making a practice more patient-centered is "understanding your population and what they need," said Dr. Fuller, a member of TMA's Council on Health Care Quality.
Care Coordination Key
Care coordination is another linchpin to a successful medical home but can be one of the more complex and expensive shifts practices must make, regardless of their size, TMA leaders say.
Dr. Crow says taking care of the whole patient involves reaching beyond primary care to the so-called "medical neighborhood" that shares in those patient care responsibilities. (See "Welcome to the Medical Neighborhood.") That includes managing transitions in and out of the hospital and other settings; interacting with specialists, subspecialists, and hospitalists; and connecting patients to community- or home-based support services.
For Drs. Crow and Fuller, coordination means being strategic about developing relationships with specialists they know and who know their patient population and keep them in the loop about their care.
For internist Temple Howell-Stampley, MD, it also means having a diverse care team at the ready. She is associate professor and medical director of outpatient services for the general internal medicine ambulatory practice sites at The University of Texas Southwestern Medical Center in Dallas, one of several medical home initiatives there.
Two clinical care coordinators help manage patients across the campus' two primary care clinics, track hospital and emergency department admissions each day, and serve as a liaison with hospitalists and specialists. Expanded access means constantly manning the phones, too, and responding to patients' email messages via the system's patient portal.
A daily game plan also goes out each day showing which doctors and nurses are covering for whom. "In order for patients to understand they have a team of providers caring for them, we refer to ourselves as such in the office. Patients learn that Dr. Howell-Stampley has a team of nurses she works with if the one they are used to is not available," she said. "We have found that patients are actually ecstatic to know they have an entire team taking care of them."
TMA and AMA policy also reinforce that the collaborative and patient safety aspects of medical homes require physician leadership.
On the one hand, that team collaboration frees physicians from tasks that can interfere with the joys of patient care, Dr. Howell-Stampley says. "So we are actively working on optimizing those workflows with nurses and assistants so we can lighten the backpack of unfinished charting and patient messages the physician takes home at the end of the day."
On the other hand, that level of manpower "takes boots on the ground, and that's money," she said. Fortunately, UT Southwestern helps provide the additional financial resources to help make some of those changes possible.
Payers: One foot in the Door
Unfortunately, payers are not lining up across the board.
As one of the first payer-initiated medical homes in Texas, Village Health Partners now contracts with most major health plans in North Texas to cover the group's care coordinator costs and offer the practice's roughly two dozen physicians bonuses for hitting certain quality and cost targets. But Dr. Crow acknowledges that level of payer engagement is not the norm in Texas.
Drs. Howell-Stampley and Fuller hoped their commitment and NCQA medical home recognition would catch insurers' attention, but that has not come to fruition.
"Payers are aware and engaged, but we haven't seen it on a wide enough scale. We want to do this because it is the right thing to do for our patients. Even though we [UT Southwestern] are doing all of these things, there is still work to be done that is essential to providing patient-centered care," Dr. Howell-Stampley said.
Without payer support, Dr. Fuller cannot afford to hire a case manager. And without a case manager, he can only do so much to coordinate patients' care, giving him cause for concern that North Hills could lose its hard-earned medical home designation when it expires at the end of the year. "We want to be able to do this, and it's a better model of care. But small medical groups are at a disadvantage. As primary care physicians, there is so much outside of a patient visit that we are responsible for and can't bill for. We know this is the right thing to do, but these are big changes."
Experts say there are alternatives for smaller practices to cross train staff or share resources by splitting the cost of a case manager. One of UT Southwestern's care coordinators, for example, is pursuing certification as a diabetic educator to offer that service once a week. Registries are another option to help practices electronically track patients' progress. (See "Revved-up Reporting.") The TMA-endorsed HIPAA-compliant mobile application, DocbookMD, also offers a new CareTeam feature. (See "DocbookMD Enhances Team Care.")
Often, NCQA's Ms. Harkins adds, the smaller medical home practices the agency works with "are used to functioning as a team and get to know their patients better. We actually see the bigger, multisite medical groups having more difficulty getting everybody on board in a standardized fashion."
Statewide Adoption Slow
Statewide adoption of the medical home, however, requires statewide commitment, Dr. Bornstein says. "It is resource-intensive; there is no question about it. The question is, where do those resources come from? It's payers." Given the high percentage of self-insured businesses in Texas, she adds, employers also "need to exert their influence to spur the creation of more medical homes for their employees."
Despite mixed research, policymakers, payers — both public and private — and some employers are in fact moving forward on the promise that the population-based primary care approach is a better way to deliver care. Still, some stakeholders appear to need more convincing as they experiment with different incentive and payment approaches.
NCQA has recognized more than 8,000 patient-centered medical homes across the country, and ACA boosted the concept with Medicare funding for several pilot projects aimed at bolstering primary care.
The 2011 Texas Legislature under Senate Bill 7 charged the state Health and Human Services Commission (HHSC) to work with Medicaid managed care organizations (MCOs) to promote the development of defined medical homes, including providing payment incentives needed to reach that goal.
In 2013, Senate Bill 58 required HHSC to establish two broader health home pilot programs for Medicaid patients with a serious mental illness and at least one other chronic condition. The Medicaid 1115 waiver (See "Medicaid Makeover," March 2013 Texas Medicine, pages 12-18) and dual-eligible (See "Dual Dilemma," May 2014 Texas Medicine, pages 33-39) demonstration projects are also testing medical home pilots for different populations, and a Texas Department of State Health Services medical home workgroup is developing a plan to ensure that all children in Texas, particularly those with special needs, have a medical home.
The Medicaid managed care model in Texas already requires health plans to assign Medicaid patients a primary care physician, explains Emily Zalkovsky, HHSC director for program management for Medicaid and the Children's Health Insurance Program. Building on that, the legislature defined the medical home more broadly than NCQA or other standards out there, for example, to give Medicaid MCOs leeway in developing their approaches.
One of those MCOs, Texas Children's Health Plan, for example, launched a pregnancy medical home pilot with the Center for Children and Women that pays a per-member, per-month rate to make sure women get their prenatal checks on time and coordinate any other maternal care needed to keep them healthy and reduce the risk of poor birth outcomes. Parkland Health Plan is using the medical home model to target children with asthma; it preauthorizes and pays physicians for a bundle of treatment at once, instead of piecemeal.
"As the managed care organizations try various things, they will be able to tell what works and what doesn't. And we hold them to certain quality standards, so they know they need to do well and incentivize their medical home providers in certain ways to make those things work," Ms. Zalkovsky said. HHSC is gathering data to report back to the legislature on what best practices might apply across the Medicaid program. In terms of boosting financial incentives, however, "the Medicaid program does have a limited amount of funding, so a lot of times when we are expected to do something new and innovative that requires more funds, the legislature would be the one to direct that."
On the commercial side, a number of Texas insurers, including Aetna, Cigna, Humana, and Blue Cross and Blue Shield of Texas (BCBSTX), are implementing various medical home programs, but sometimes only in select regions of the state and each with its own standards.
Some employers are jumping on board, too. For example, one of the Aetna health plans the Teacher Retirement System of Texas offers to active employees requires workers in certain counties to choose an accountable care organization as their medical home. The Employees Retirement System of Texas has a similar program.
Time Will Tell
BCBSTX is experimenting with two different models that focus on prevention in relatively healthy patients and enhanced disease management for more chronically ill patients with multiple conditions.
Texas Blues Senior Medical Director Robert Morrow, MD, says the insurer is "very sensitive" to the fact that medical homes don't spring up overnight, and it offers incentive payments in the form of a care coordination fee to help cover the cost of and promote effective care management and in the form of shared savings doctors' efforts help generate.
"But this is a gradual process, so they [medical home models] are not available immediately in all areas. We expect as we learn more and get more feedback from our members and our physicians and other providers, we will continue to refine it so the whole thing continues to improve."
BCBSTX data so far show the enhanced medical home models are helping decrease monthly per-member costs, hospital stays, and emergency department visits, while other BCBSTX pilots did not show significant improvements.
"But it's hard to argue with value, so the opportunity is there, and it's up to us as payers and physicians and other providers to work together to continue to improve our ability to provide care, but also demonstrate value in the care we provide," Dr. Morrow said.
Although the growth continues and the medical home continues to evolve, available research still offers no definitive answer on whether the model will live up to its promise.
A January report released by the Patient-Centered Primary Care Collaborative, reviewed 20 peer-reviewed studies on medical homes and found 60 percent of the evaluations showed decreases in care costs or use of unnecessary or avoidable services; 30 percent reported improvements in population health. The results come from health plans, integrated health systems, academic medical centers, multipayer initiatives, and the military.
On the heels of that report, a study published in the Feb. 26 issue of the Journal of the American Medical Association generated significant buzz when it found a Pennsylvania medical home pilot project, after three years, failed to reduce costs and only modestly improved outcomes.
Part of the problem, says Dr. Bornstein, is that change takes time, and it's difficult to measure the short-term impact of several different interventions running at once. Meanwhile, states, health plans, and other entities perpetuate a variety of standards, with no uniform payment criteria.
But just as the medical home takes collaboration among physicians and patients, Dr. Bornstein says furthering the model will take collaboration between the state and payers to draft just the right blueprint.
Amy Lynn Sorrel can be reached by telephone at (800) 880-1300, ext. 1392, or (512) 370-1392; by fax at (512) 370-1629; or by email.
DocbookMD Enhances Team Care
DocbookMD now allows TMA member physicians to invite their nurses, physician assistants, and other office staff to join them on the secure mobile and web-based application via the CareTeam feature.
- The entire care team can send and receive HIPAA-secure messages, including images like x-rays and EKGs.
- Physicians remain at the center of patient care and can use DocbookMD to coordinate care across any type of practice setting.
- Physicians decide whom to invite and who can send them messages.
It's easy and free for members to get DocbookMD:
- Search DocbookMD in your mobile device's app store and download the application.
- Open the app, and tap "I'm New to DocbookMD."
- Enter your email address, and create your DocbookMD password.
- If you use an email address other than the one TMA has on file, you will be asked to enter your TMA member ID to complete registration. Contact the TMA Knowledge Center at (800) 880-7955 if you don't know your ID.
DocbookMD is a free, exclusive benefit for TMA physicians. Learn more about how DocbookMD breaks down the communication barriers among physicians, transforming collaboration and improving patient care.
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