Alfred Bove, M.D., a cardiologist at Temple University Physicians in Philadelphia, agrees that the primary care patient-centered medical home makes sense for patients who have no complicated chronic conditions. But what about patients suffering from cardiac arrhythmia or late-stage kidney failure or rheumatoid arthritis?
"We have moved into an era of chronic disease in which people are living longer and they often have multiple diseases like diabetes, heart disease, arthritis and asthma," he says. "It's easier for [specialists] to go back and handle the easier parts of health care, including prevention and education, than it is for a primary care doc to try to jump into the very complicated world of late-stage heart disease."
Bove, a former president of the American College of Cardiology, wants the patient-centered medical home extended to specialty practices, allowing a cardiologist or other specialist to be recognized as a patient's primary physician.
He has plenty of company. The National Committee for Quality Assurance has received many inquiries from specialty and subspecialty practices, including ob-gyn, cardiology, endocrinology, oncology and others who wish to receive NCQA recognition as a patient-centered medical home. That's why NCQA is developing a new specialty practice recognition program set to be launched next spring.
NCQA does not use the term "medical home" for specialty practices, reserving it instead for primary care practices. But the program will recognize specialty practices that follow key tenets of the medical home model, namely:
- Coordinated care
- Timely access to care
- Use of information technology to reduce duplicative tests
- Improved communication with patients
- Continuous quality improvement
"The emphasis with this specialty practice program is really on providing patient access to a specialist, the coordination of care between primary care and specialist, and the transition from one to the other," says Patricia Barrett, vice president of product development for NCQA. "As the patient goes back and forth, if need be, the patient is transitioned in a seamless way between primary care and the specialty practice."
Why so popular?
The primary care patient-centered medical home, or PCMH, is based on joint principles published in 2007 by the American Academy of Pediatrics, the American College of Physicians and two other primary care societies.
They define a medical home as a practice in which each patient has an ongoing relationship with a personal physician who leads a team of individuals within the practice who collectively provide "whole person care," including referrals if appropriate. A medical home coordinates care across the health care system; uses information technology to make sure patients get the right care; emphasizes quality and safety; and enhances access by expanded hours, open scheduling or other means.
A few organizations offer accreditation, certification or recognition programs to differentiate primary care practices that meet their medical home standards, but relatively few practices pursued the designation until insurers got interested.
In the last three years, private payers have become very interested. Many national and regional insurers have developed incentive programs to encourage primary care practices to adopt the medical home model, believing that it would improve patient care and lower total costs of care.
Evidence is beginning to emerge that they were right. Blue Cross Blue Shield of Michigan, which has 994 PCMH practices, reports that physicians using the medical home model last year had an 8.3 percent lower rate of adult high-tech radiology use, a 9.3 percent lower rate of adult emergency department visits and a 3 percent higher rate of generic drug prescriptions than their non-PCMH counterparts. In Horizon Healthcare Services' pilot in New Jersey, medical home practices had a 21 percent lower rate of inpatient admissions in 2011 than a comparison group. In Colorado, Wellpoint reported a return on investment of at least 250 percent for its participation in the state's multipayer PCMH pilot.
Meanwhile, the federal government also is evaluating the medical home model through a three-year multipayer advanced primary care demonstration, a Federally Qualified Health Center advanced primary care demonstration and various projects undertaken by the Center for Medicare & Medicaid Innovation.
All this focus prompts some specialty physicians to ask two questions: If the medical home model offers such promising results for primary care, why would it not offer even greater outcomes for patients with complex and high-cost chronic conditions? And if insurers are willing to pay primary care physicians more money if they adopt the medical home model, why would they not consider doing the same for specialty physicians?
Specialty medical homes today
A few specialty practices — including the AIDS Resource Center of Wisconsin Medical Center in Milwaukee and Consultants in Medical Oncology & Hematology in suburban Philadelphia (CMOH) — have met the NCQA's criteria for primary care medical homes and been recognized officially by the program.
More typically, however, specialists who use the "medical home" term are describing a specific approach to care unrelated to standards set by NCQA or any other organization. For example, Community Care of North Carolina, in conjunction with two state agencies, is encouraging obstetrical practices to become "pregnancy medical homes." Obstetricians who do so agree to conduct risk screenings for their pregnant patients covered by Medicaid, coordinate patient care with a CCNC care manager, participate in quality improvement efforts and eliminate elective early deliveries and unnecessary cesarean sections. In return, they receive bonus payments, exemption from prior approval for ultrasounds and care management support.
Several oncology practices, including CMOH, Wilshire Oncology Medical Group in Los Angeles and Cancer & Hematology Centers of Western Michigan, are in medical home pilot contracts with private payers. Enthused about early results, Community Oncology Alliance, which advocates for oncology practices, is developing a step-by-step blueprint to encourage all oncology practices to adopt the model.
Earlier this year, Bove co-authored a health policy statement, published in the Journal of the American College of Cardiology, that recommended development of a patient-centered medical home for cardiovascular disease, which he calls the PCMH-CVD. "That puts the burden on us to be the patient's primary care physician and be willing to see the patients if they have something that isn't related to their heart disease and to make sure they get their immunizations and annual prevention things," he says.
Brian Silverstein, M.D., a consultant and president of HC Wisdom, expects the stand-alone medical home model for specialty care to gain only limited traction because of implementation challenges. He formerly headed the CareFirst BlueCross BlueShield PCMH Program, which acts as a primary care accountable care organization with more than 3,600 primary care physicians and nurse practitioners.
While some payers may wish to develop and manage contracts specific to a specialty, many will be reluctant to do so because of the complexity involved. "This can be a great idea that is going to save millions of dollars and make all the sense in the world, but if it's going to cost millions of dollars to set up the program and administer it, at the end of the day, it is just not affordable," he says.
Bove believes the PMCH-CVD could usher in a new payment model that would enhance patient care, lower costs to payers and improve incomes of cardiologists who can prove they are doing a good job. "The whole world we're in is seriously misguided in the way we get paid," he says. "If I do a good job taking care of a heart failure patient, I may see that patient four times a year and get paid about $50 a visit. If I don't take care of the patient and they get sick and end up in the hospital, I make $10,000 or $15,000 in payments for taking care of the hospitalization, the echos and all the other things. The system is backward."
He also thinks it is a step backward to expect patients with complicated heart disease to consider a primary care physician to be their medical home. He says, "For a lot of my patients, when I ask them who their primary care physician is, they look at me and say, 'You are.'"
Silverstein says the goal of a PCMH is not to have primary care physicians deliver care that otherwise would be done by the specialists, but rather to make sure the patient gets to the best specialist at the right time. Patients with a single-condition chronic disease will believe their specialist is their PCP and even go to that specialist for simple primary care, he says, but if another chronic condition emerges, a primary care physician is needed to coordinate.
"It is clear that the specialist needs to have tight coordination with the primary care physicians," Silverstein says. "The key questions are: Who is working for whom? Where do the funds flow and for what services? Do the primary care docs get the capitation and contract with the specialists or visa versa?"
Many medical home contracts involve per-member, per-month fees to the physician practice, and a particular problem is attributing patients to the right medical home. "If I've got one deal with the oncologist and one deal with the cardiologist, what happens if a congestive heart failure patient gets cancer? Whose responsibility is it then?" Silverstein says. "And by the way, if I do a deal with primary care physicians and a patient gets cancer, now are they out of the primary care deal?"
Some payers encouraged NCQA to develop its specialty practice recognition program, but Barrett doesn't think they're necessarily willing to pay specialists more for medical home services.
In the case of primary care, payers were looking for ways to increase physician pay and are willing to make per-patient, per-month payments that support care coordination, increased access and other elements of the medical home model. "People aren't generally yelling up and down that specialty care isn't being reimbursed enough, whereas there was clearly that movement in the primary care arena," she says. "The PCMH can serve as a mechanism for saying, 'We're getting something different, and we're going to reward that with a different payment structure.'"
That said, a different payment model will be required for specialty practices to transform themselves into medical homes. "It's such a drastically different way of practicing, and it doesn't match up with the way that reimbursement is typically doled out," Barrett says. "You can't support the resources you need properly in the [PCMH] model under the old [fee-for-service] payment approach."
Silverstein thinks specialty practices may have more success negotiating with primary care-led ACOs than directly with payers.
Bruce Gould, M.D., medical director of Northwest Georgia Oncology Centers, chairs the Community Oncology Alliance's medical home initiative steering committee. He says oncology medical homes play into insurers' goal of value-based care. Oncology practices will have to report quality and efficiency data that document the value they deliver. "In the long term, the benefit to [payers] will be that the cost curve will be bent, and they'll get better value for their health care dollar," he says.
FRAMING THE ISSUE:
- Patient-centered medical homes organized around primary care practices are intended to provide timely, coordinated care that is more effective and more efficient.
- Oncologists, cardiologists and other specialists say they can do the same for their chronically ill patients who, in many cases, consider the specialists their primary physicians.
- Skeptics ask what happens when a specialist's patient develops another ailment that requires care coordination with another type of physician.
- Some payers may be reluctant to support specialty medical homes because of their complexity. Others advocate for a new payment model to encourage specialists to embrace the idea.
The Community Oncology Alliance is convinced that the medical home model is the future of cancer care, and it is developing a toolkit to help all oncology practices to convert their practices. Bruce J. Gould, M.D., chair of the steering committee for COA's medical home initiative, says oncologists cannot control the high cost of new therapies, some of which cost $100,000 per course of treatment, but they can manage patient care in ways that reduce emergency department visits, inpatient stays, imaging utilization and the use of drug therapy on patients who are no longer benefiting from it. Gould, medical director of Northwest Georgia Oncology Centers, identified the elements of the oncology medical home:
- Compliance with best practice guidelines for the use of oncology drugs, supportive care drugs, radiation therapy and other diagnostic and treatment services
- Patient satisfaction surveys that identify deficiencies in a practice
- Use of nurse navigators or other staff to call high-risk patients frequently to monitor the side effects of their treatment
- Education protocols that train patients to recognize serious symptoms and report them before an ED visit is needed
- Extended office hours
- Use of midlevel practitioners to expedite admissions and coordinate care for hospitalized patients so their inpatient stays are as short as possible.
- Early end-of-life planning discussions
- Reporting quality measures to payers, including ED and hospitalization rates and rates of chemotherapy use near the time of death
America's first oncology medical home
If the medical home model becomes widespread in oncology, payers, providers and patients will have John Sprandio, M.D., to thank. His nine-physician practice — Consultants in Medical Oncology & Hematology in southeastern Pennsylvania — began a transformation in 2004 that led to becoming the first oncology practice recognized as a Level III patient-centered medical home by the National Committee for Quality Assurance.
The results: Estimated savings to payers of $1 million per physician per year. That tally sums up the savings from reduced utilization of many health care resources, including:
- 68% fewer emergency department visits per chemotherapy patient in 2011 than in 2006
- 51% drop in the rate of hospital admissions per chemotherapy patient between 2007 and 2011
- 21% decline in length of stay for admitted patients over three years ending in 2011
- 12% decrease in outpatient visits per patient per year for patients receiving chemotherapy
There was also a decreased use of chemotherapy, ED admissions, and hospital admissions in the last 30 days of life.
All results, Sprandio says, come from applying the NCQA primary care medical home standards to cancer care. Using health care information technology, standardized care protocols and a staffing plan that proactively helps patients manage their health, CMOH is increasing the quality of care, decreasing the cost and freeing up capacity to treat more patients.
By reengineering the way that care is delivered in the practice, CMOH cut its support staff from 72 FTEs to 52, converted to electronic health records, and reassigned administrative assistants to work as patient navigators. "Our patient navigators schedule and track every test and every specialty or primary care appointment," he says. "If a patient doesn't keep her MRI appointment on Monday and we don't receive the result on Tuesday, our patient navigator is calling to reschedule."
Patient education is standardized so patients hear the same information from physicians, nurses who call to check on their side effects, and nurses who staff the triage phone lines. That includes training patients to monitor their own symptoms and take advantage of same-day appointments. "We're making them responsible to be better reporters. If they wake up at 8 a.m. and think they might have a problem, they better call by 8:15," he says. "Don't call us at 3:30 or 4 and then spend eight hours in the ER or be admitted unnecessarily." — Lola Butcher