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A skeptical look at primary care in the medical home


Robert Berenson and Rachel Burton look at the solidity or lack thereof of the primary-care foundation of the patient-centered medical home (PCMH)

They write  in HealthAffairs “{A} recent summary of the latest evidence found reason for optimism about the potential impact of the PCMH model, not only on quality but also physician morale — raising the hope that the proliferation of the PCMH model might attract more physicians to careers in primary care.

“At the same time, more robust studies that have used difference-in-differences analyses—controlling for the likelihood that practices that become PCMHs might be higher performers to start with—had less impressive results, especially regarding healthcare spending….”

“But there’s a more fundamental issue to consider regarding which aspects of primary care practice make the difference in performance. Many of the versions of the PCMH—and the accompanying recognition instruments that assess practice adoption of the PCMH model—do not assure that the well-established four ‘pillars’ of primary care are robustly adopted by PCMH practices. Rather, it’s simply assumed, despite growing evidence to the contrary, that practices are meeting the ‘four C’s,’….— providing first contact, continuity, comprehensiveness, and coordination.

“We would suggest the current emphasis of PCMH demonstrations and models on the fourth C, care coordination, is partly a reaction to decline in primary-care commitments to the three other C’s,contact, continuity, and comprehensiveness — decline that seems to have been simply accepted as facts of life by most PCMH architects. It’s no wonder the PCMH emphasizes care coordination — much of the care received by primary care clinicians’ patients is now being performed by others, without their involvement.”

Lack of risk for physicians boosts CareFirst PCMH initiative


Physicians like Baltimore/Washington, D.C.-based CareFirst BlueCross BlueShield’s patient-centered medical home (PCMH) initiative because it offers financial incentives but includes no penalties or risks for providers, says  President and CEO Chet Burrell.

FierceHealthPayer reported: “Speaking to the American Academy of Family Physicians (AAFP) last week, Burrell explained that CareFirst’s PCMH model, which began in 2011, requires participants to form groups of five to 15 physicians known as panels, which are graded based on patient access, patient engagement and appropriate use of services.

“In 2014, the average participating practice received $41,000 in revenue from the program, in addition to the flat 12 percent participation fee each practice receives every year. Importantly, the program does not reduce payments for practices that receive low or average scores, Burrell noted,” the news service reported

“No physician in his right mind ought to take insurance risk,” Burrell said.

“Though the program is voluntary, Burrell says 90 percent of the plan’s 4,400 physicians have chosen to participate, meaning it now covers 3.4 million individuals in Maryland, Virginia and the District of Columbia. CareFirst itself has also benefitted, as its PCMH program saved the insurer $40 million in its first year, and years later, continues to produce “remarkable and energizing” medical cost trends, Burrell said last July.”


MIPS looms, but maybe you can opt out


Providers are girding their loins to comply not only  with the next stage of the Meaningful Use program, but also a  new mandated electronic reporting requirement: Medicare’s Merit-based Incentive Payment System (MIPS).

The MIPS combines parts of the Physician Quality Reporting System (PQRS), the Value-based Payment Modifier, and Meaningful Use into one single program based on quality, resource use and clinical-practice improvement.

Robert Tennant, senior policy adviser with the Medical Group Management Association (MGMA),  told MedPage Today that the two programs are very inter-twined:
“Even though Meaningful Use was sunsetted, it’s now effectively 25% of your MIPS score, so it never really goes away.” And because it is so much of the MIPS score, “it’s potentially more impactful on your reimbursement.”

But Linda Delo, D.O., a family physician in Port Saint Lucie, Fla., told the online news service that, as MedPage paraphrased her, “{P]hysicians can get out from under MIPS in some cases if they become part of an alternative payment model such as an Accountable Care Organization (ACO), a bundled payment model, or a patient-centered medical home (PCMH), rather than continue in the traditional fee-for-service Medicare program.”


R.I. pushes insurers to PCMHs


Kathleen Hittner, the Rhode Island health insurance commissioner, announced an overhaul of the office’s “affordability standards.”  The change will require insurers to increase the percentage of their primary-care networks  running as “patient-centered medical homes (PCMHs)” by 5 percentage points in 2016.

It’s  mostly part of an effort by the new governor, Gina Raimondo, to bring the Medicaid costs under control.

The state announced:

“The Care Transformation Plan requires insurers to increase the percentage of their primary care network functioning as a PCMH by 5 percentage points for 2016 and sets a target of 80% of Rhode Island primary-care clinicians practicing in a PCMH by 2019. The Alternative Payment Methodology Plan establishes payment reform targets for commercial insurers and sets a target for at least 30% of insured medical payments to be made through an alternative payment model by 2016. The payment reform targets will increase the use of payments that emphasize value rather than volume and include efficiency-based global and bundled payment models, as well as payments based on quality performance.”

Thumbs up for pediatric telemedicine



The American Academy of Pediatrics has endorsed telemedicine for children, but with caveats, especially that it be integrated into the patient-centered medical home.

After a study, the  AAP Committee on Pediatric Workforce backed telemedicine services within the PCMH to improve the quality, efficiency and cost-effectiveness of patient care.

But at the same time, the committee  discouraged “fragmented care” from  such third-party providers as retail health clinics, arguing that it disrupts care and undermines the PCMH model.

The committee said  that telemedicine was particularly useful for children in rural areas and those needing care from a specialist.

They said that  telemedicine  can help increase the comprehensiveness of care delivered by improving communication between the patient and the care team.

The authors said that telemedicine has led to more appropriate specialist referrals and fewer diagnostic redundancies.

Still, the complained that it remains difficult for providers to receive reimbursement for telemedicine consultations, particularly from public insurance programs such as Medicaid. But then, telemedicine is still in its early innings.





The PCMH and/or the ACO route?

Should physician groups become  patient-centered medical homes (PCMH) and/or affiliate with  Accountable Care Organizations? 

This Medical Economics article provides some guidance.

 “Because the PCMH and ACO share common goals of lowering costs and improving patient outcomes, physicians often think of them interchangeably. But they differ in that a PCMH is an approach to care for an individual practice, whereas an ACO is a method of reimbursing a network of providers. ‘Basically, the PCMH is a care delivery mechanism, while the ACO is a payment mechanism,’ explains David Gans, FACMPE, senior industry affairs fellow with the Medical Group Management Association (MGMA).”’

Home, sweet PCMH


The American Journal of Managed Care  last month  published the results of a  pilot study about a patient-centered medical home (PCMH) in a busy and urban primary-care practice that showed better patient outcomes and without workflow disruptions.

Medical Economics says the study found providers and patients both liked the practice, which showed such nice outcomes as  increased life expectancy (12 months versus 6.7 months for those in the control group) and  greater success in stop-smoking efforts.

”The study’s authors say the program was beneficial and not difficult to implement, despite fears over the length of time office visits in the PCMH would require.”

Less happily —  and in a contradiction”? —   the study’s authors said that  “It is increasingly appreciated that while primary care should become more personalized and patient-centered, time constraints may oppose these goals.”

”The study notes that clinic staff can obtain vital signs and conduct routine interviewing, while another team member can resolve appointment and logistical issues, resulting in a 60-minute visit  {for a patient} divided between four or five different roles within the clinic.”

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