Who’S Afraid Of The Medical Home?

Obamacare is hither to stay, as well as amongst it a host of initiatives small-scale as well as large, some intended as well as some non so much so, targeting massive transformation of the wellness aid delivery system. One of those initiatives involves the adoption of the principles of a Patient Centered Medical Home (PCMH) for primary aid equally formulated past times the primary aid medical associations, as well as to a large extent, equally translated into operational processes past times the National Committee for Quality Assurance (NCQA). There are other implementations of the PCMH seat forrad past times populace as well as private organizations, but NCQA’s Medical Home recognition programme is considered the gilt touchstone for PCMH. The PCMH concept is also hither to stay, as well as equally is the instance amongst Obamacare, the Medical Home model has its supporters, its detractors as well as all sorts of misconceptions as well as implementation missteps.

If you lot randomly inquire a primary aid physician nigh his/her thought on the Patient Centered Medical Home model of primary care, you lot volition most probable acquire i of the answers listed below inward gild of increasing prevalence:

1. Absolutely fantastic way to exercise medicine. We’ve been doing this for a land as well as are a Level III recognized Medical Home.
2. The thought is expert as well as nosotros are currently making the transition as well as working on obtaining NCQA recognition. It’s non easy, but nosotros are hopeful.
3. We are share of a PCMH airplane pilot inward our state. It’s a lot of operate as well as I am non convinced that it volition receive got whatever benefits for my practice.
4. I read nigh it, but I can’t afford to hire dieticians as well as social workers as well as pass fourth dimension on all the newspaper work.
5. I don’t receive got fourth dimension for this.  Just a bunch of authorities regulations that create aught for patient care.
6. This is the in conclusion boom inward the coffin of primary care. It’s going to drive all remaining independent physicians out of practice, which is what the authorities wants anyway.
7. My mother in law is inward an assisted living facility, but other than that I don’t receive got whatever patients inward nursing homes….. I don’t accept Medicaid.
8. Say that again….?

Just similar Obamacare is non something invented past times overzealous socialists, but the brainchild of extremely conservative thinking, the PCMH is non a authorities invention, but instead it is based on a argument made past times physician associations attempting to define expert primary aid as well as the demand for insurers to pay to a greater extent than for such excellence. The devil of course of instruction is inward the details. It’s been said that the “official” NCQA PCMH requirements consist of likewise many details, as well as that some of those details are bureaucratic inward nature, burdensome, expensive as well as contribute piddling to patient care. It’s been said that truthful character of aid as well as exercise transformation, whatever that may be, is largely independent of counting points, formal testing, certifications as well as recognitions.  Granted, all these contentions appear reasonable, but earlier deciding to walk away, how nigh a quick bird’s oculus tour of what NCQA PCMH recognition actually is?

The half dozen parts of formal NCQA 2011 PCMH recognition are called Standards. Let’s accept a critical await at each i as well as greenback the gild inward which they are arranged.

Standard #1 - Enhance Access as well as Continuity – Continuity hither refers to people having a personal physician instead of seeing whoever happens to receive got fourth dimension that day. I don’t know many practices where this is non the instance anyway, but it’s hard to fence against the demand to construct a long term human relationship betwixt patients as well as their doctors, as well as it’s fifty-fifty harder to fence against this beingness the #1 foundational requirement of delivering high character longitudinal patient care. Note that past times Definition solo practices are automatically prepare to aid for patients this way (just saying…). The minute share of this Standard is a fight to a greater extent than problematic from a physician’s betoken of view, because it does require availability afterward hours as well as seeing patients the same twenty-four hours equally much equally possible. It is non an slowly employment to firstly tinkering amongst your schedule, if you lot are non currently offering same-day appointments, as well as done haphazardly, it may receive got serious fiscal implications to your practice. How nigh beingness available afterward hours, especially for a solo or rattling small-scale practice? How nigh your household unit of measurement as well as personal life? If you lot are i of the novel concierge docs amongst a tiny panel of well-behaved patients, this is champaign non an issue. If you lot receive got 2500 patients, or so, on your panel, some creative thinking may live on required. How would your patients react if, say, every Tuesday you’d firstly seeing patients from 12 pm to 8 pm? Or if you lot unopen early Wednesdays as well as twice a calendar month you lot saw patients on Sat mornings? Or if you lot had an organisation amongst a pair of other practices to render urgent aid at strange hours on a rotating basis?

Influenza A virus subtype H5N1 recent study inward the Annals of Family Medicine flora that total wellness aid expenditures were 10.4% lower for patients who had access to extended hours of care. This is bang-up tidings for the “system”, but how nigh benefits to you lot as well as your practice? Whether you lot similar it or not, you lot are straightaway competing against delineate of piece of work organisation models amongst extremely depression overhead, such equally grocery shop clinics as well as virtual tele-medicine clinics, offering pseudo-primary-care to your rushed as well as hurried patients for elementary needs, leaving you lot to bargain amongst complex visits that toll you lot a lot to deliver, but pay equally much (or equally little) equally the elementary ones. Unless you lot firstly thinking exterior the box, your model of delineate of piece of work organisation is destined to acquire obsolete. Offering some electronic visits, providing hours for urgent aid needs as well as collaborating amongst others on extended coverage may rattling good live on a thing of survival. Interestingly enough, some other recent JAMA study, although express to community wellness centers, finds measurable correlation betwixt access as well as continuity as well as lower operational costs per unit of measurement of service. There should live on rattling piddling incertitude at this betoken that Standard #1 is the identify to firstly operate on the viability of whatever practice, or ignored at meaning peril.

Standard #2 - Identify as well as Manage Patient Populations – This i sounds onerous as well as a difference from individualized patient care, but is it actually so? The “populations” term notwithstanding, all this Standard requires is that you lot document patient demographics as well as clinical information inward the nautical chart (seriously?), that you lot accept expert histories as well as that you lot ship reminders to your patients to remove heed their chronic and/or preventive aid needs. There is actually aught hither that a expert primary aid physician doesn’t already do, as well as in all probability to a much greater extent than the NCQA standards specify. The i thing that may live on unlike is that this Standard talks nigh proactive reminders to patients that don’t come upward inward to run across you lot on their own. Good for delineate of piece of work organisation as well as definitely expert for patient aid on an private level.

Standard #3 - Plan as well as Manage Care – Another argument of the obvious, but this touchstone uses terminology that may enhance some eyebrows. For example, it asks that your aid is evidence-based. Is your aid non evidence-based? Surely you lot create upward one's remove heed how to care for patients based on your education, what you lot learned along the years, books, articles as well as latest research, instead of throwing darts at a random treatments listing hanging inward your office. And this is actually all at that spot is to this Standard, other than practicing medicine, i.e. seeing patients, evaluating conditions, planning care, talking to patients, as well as mostly speaking, beingness their doctor. 

Standard #4 - Provide Self-Care Support as well as Community Resources – This may audio similar the novel historic current fluff of patients taking aid of themselves, as well as granted, at that spot is some of that here, but the details are i time to a greater extent than pretty straightforward inward their intent to receive got patients empathise their atmospheric condition as well as create something nigh it. Primary aid docs don’t commonly lucifer the much publicized portrait of aloof as well as paternalistic doctors who won’t give you lot the fourth dimension of day. It is the fourth dimension constraints inward fully loaded practices that may foreclose some from fully engaging amongst their patients, as well as no certification procedure volition alter that without proper shift inward reimbursement, or a alter to a to a greater extent than remove exercise model amongst smaller patient panels. This Standard’s feasibility is also highly subject on patients themselves, but at that spot are elementary things you lot as well as your staff tin forcefulness out create to amend enable patients to accept some responsibleness for their ain wellness (most of which you lot are in all probability doing already), as well as this is all this Standard is about.

Standard #5 - Track as well as Coordinate Care – Do you lot ship patients to specialists as well as so forget all nigh them? Do you lot gild lab tests as well as don’t aid if the results come upward inward or non or if they are normal or not? Do you lot acquire calls from the infirmary notifying you lot that i of your patients was admitted, as well as you lot hang upward thinking that this is non your problem? No? Then you lot are tracking as well as coordinating care. Can you lot create more? Probably, but hither you lot are largely at the mercy of specialists as well as hospitals inward particular. You most probable already receive got tickler lists to aid remind your staff nigh getting specialists notes as well as essay results, but it is extremely hard to receive got the infirmary contact you lot if you lot are non admitting your ain patients (and sometimes fifty-fifty if you lot do). There is exertion (and costs) involved inward amend tracking as well as amend coordination as well as payers are starting to accept notice equally evidenced past times the latest aid coordination CPTs added to the Medicare physician fee schedule.

Standard #6 - Measure as well as Improve Performance – Here it is. This is the measuring, reporting as well as all administrating handbag of requirements, consummate amongst patient satisfaction surveys, sending information to payers as well as using electronic medical records. While most items hither are optional, a medical domicile is required to laid some improvement goals for clinical measures (just destination setting, non necessarily outcomes). So afterward doing everything outlined inward previous Standards, this is where the supposition is implicitly made that a medical domicile should live on able to continuously improve the aid it provides. Perhaps you lot believe that you lot are already providing splendid care, as well as no incertitude most of you lot do, but is at that spot anything to a greater extent than you lot tin forcefulness out do? This Standard is quest you lot to consider this question, as well as if you lot receive got an answer, commence acting on it. And yes, this likewise may accept to a greater extent than fourth dimension as well as to a greater extent than exertion on your part, as well as thence live on subject on payments to back upward these efforts.

Did I leave of absence anything out? If your thought of the PCMH was something along the lines of #6 above, you lot are in all probability wondering nigh some “strategic” omissions. How nigh all that “team care” as well as nurse practitioners? How nigh those instance managers as well as dieticians? What of the demand to buy, implement as well as purpose an expensive EMR? Well, for starters these things are optional inward nature. Unless you lot are a squad of one, you lot already receive got people helping you lot out amongst patient aid as well as administration, as well as you lot are non required to purpose or augment your staff to a greater extent than than you lot are comfortable with. Influenza A virus subtype H5N1 expert EMR should help, but it is non mandatory either. And yes, NCQA volition recognize nurse practitioner led practices equally medical homes, but this is reflective of legislation at State levels, as well as it should live on appropriately addressed at a policy as well as legislative degree equally well. As to the infamous amounts of paperwork involved, yes, at that spot is plenty of that, but at that spot is also plenty of aid out at that spot as well as you lot only demand to notice it.

On the surface the NCQA PCMH recognition procedure is an administrative essay for primary care, but if you lot await at it carefully, you lot tin forcefulness out run across that it is also a logically ordered roadmap for character primary aid as well as a tool for you lot to accept a fresh await at your exercise as well as seat it to alter amongst the times without having to sacrifice your ethics as well as your principles. Some things inward this roadmap are at the pump of what you lot create every day, others are things that you lot may desire to create if fourth dimension as well as finances allowed, as well as few are inward the realm of “forget it”. Unlike Meaningful Use, the NCQA PCMH “test” is non an all-or-nothing proffer as well as at that spot is reasonable liberty for you lot to discard those “forget it” items, or postpone the wishful thinking for a amend day. There should live on fiscal benefits accruing from only doing some of the things on this roadmap (such equally Standard #1), as well as at that spot are fiscal incentives from payers for doing other things or from only “passing the test”.

The medical domicile is a timeless model of care, repackaged for these troubled as well as technology scientific discipline driven times, as well as equally such, it is also a delineate of piece of work organisation model for the time to come of primary care. You could approach the entire exercise equally nonetheless some other payer as well as authorities mandated intrusion, or you lot could brand this roadmap your own, as well as await at it equally a agency past times which to refine as well as sustain an already splendid practice. It is ultimately all upward to you.

[Disclosure: I am the founder of BizMed, a companionship whose mission is to back upward the viability of independent medical practice, as well as to that halt it offers costless software tools to trim back administrative complexity inward private exercise inward general, as well as PCMH recognition inward particular]