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Regents consider medical home's business model

From the June ACP Observer, copyright © 2007 by the American College of Physicians.

By Jessica Berthold

SAN DIEGO—The Patient-Centered Medical Home (PCMH) was a primary focus of discussion and action at April's Board of Regents meeting at Internal Medicine 2007, with Regents venting hopes and concerns about the model being supported by the College and other medical groups.

The PCMH would modify the current fee-for-service reimbursement model and pay primary care doctors for coordinating all aspects of a patient care.

The Regents voted to work with outside consultants to determine how much it will cost practices and purchasers to implement various elements of the model, including a plan for reimbursement. They also voted to hire a project coordinator to oversee national demonstration projects on the model.

"We need to make the business case for this (model) and be leaders," said Regent Kathleen M. Weaver, MACP. "We need to be proactive, not reactive."

Joseph W. Stubbs, FACP


Joseph W. Stubbs, FACP



The College will issue a request for proposals before it hires consultants with the kind of econometric expertise needed to determine the value and costs of each of the model's components. One such detail includes revision of payment policies such that physicians are reimbursed for time spent coordinating care by e-mail and phone, not just for face-to-face visits, noted Robert Doherty, ACP Senior Vice President of Governmental Affairs and Public Policy.

It's critical that the College tackle payment structure from the start, lest it be done for them by other interested parties, said Regent Joseph W. Stubbs, FACP.

"Insurance companies and the government are looking for assistance (on determining costs). If we can't provide this information, someone else will," Dr. Stubbs said. "We want to be at the table to tell payers what the cost will be."

Echoing the concerns of other Regents about the model's financial feasibility, Regent Stephen G. Pauker, MACP, said he feared it was "a house of cards." Mr. Doherty responded that data from other countries support the notion that the PCMH could work in the U.S.

"The data are solid. Health care systems that value primary care services have better capital expenditures," Mr. Doherty said.

However, Regent Faith T. Fitzgerald, MACP, noted there were some potential differences between patients in the U.S. and other nations. "We need to address the techno-philia and specialty-philia in this country. We can't be seen as the mendacious creatures who took away the toys," Dr. Fitzgerald said.

A target of particular concern was small practices, since the PCMH involves a substantial investment in technology like electronic health records. "If physicians can't pay for EHRs, it's not going to happen," said Regent Virginia U. Collier, FACP.

John Tooker, FACP, Executive Vice President and CEO of the College, agreed, saying that the College's model calls for an infusion of capital to help practices handle the information requirements of the PCMH, as well as a per-patient care coordination fee.

"The bottom line is, there has to be an infusion of money into primary care," Dr. Tooker said in a combined meeting of the boards of Regents and Governors.

Mr. Doherty also noted that the College's plan includes a "laddered" approach that will allow small practices to make a gradual transition to a full-scale PCMH practice. In addition, he spoke with Regents about the College's success in working with large employers, consumer groups and other physician groups to agree on a unified set of principles for patient-centered care.

Challenges that ACP must address with the PCMH include the misconception that it is simply managed care in a different iteration, and fears by surgeons and specialists that the model will take business away from them, Mr. Doherty added.

Measuring performance

The Regents also approved a statement of principles governing the process by which physicians can appeal performance measurement ratings. They call for allowing doctors to review their ratings, as well as request reconsideration without fees or penalties, before the ratings are released to the public. If a physician still contests a rating after all means of reconsideration have been exhausted, he or she should be able to include comments with the rating in the public report, they said.

Also passed at the meeting were:

  • A resolution to promote legislation that provides medical malpractice liability protection for physicians who volunteer care.
  • Clinical practice guidelines (pending publication) for pharmacological treatment of dementia.
  • Recommendations to globalize the College's activities by, for example, increasing funding for the International Speakers Program, enhancing recruitment abroad and translating key educational materials.
  • A resolution to collaborate with subspecialty societies to increase funding for graduate medical education for Internal Medicine and subspecialty training programs.

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Doctors need extra time to treat patients with limited English

Nearly two-thirds of internists have patients with Limited English Proficiency (LEP), yet physicians are rarely reimbursed for the extra time and expense of treating these patients, a recent survey of College members found.

William E. Golden, MACP


William E. Golden, MACP



"On average, patients with LEP comprise 12% of active patients in the practices of ACP member internists," said College President Lynne M. Kirk, MACP. "Physicians encounter such patients on a fairly frequent basis."

The College's Board of Regents voted at its April meeting to ask Medicare to reimburse doctors for the extra expense and time of treating Limited English Patients, and to advocate for a national clearinghouse of translated documents and patient education materials.

Because patients with limited English have more difficulty understanding basic health information, they usually require more time during office visits, the survey found. Roughly half of survey respondents said they spend an extra five to 15 minutes with LEP patients versus those who are proficient in English, while another quarter reported spending an extra 16 to 30 minutes. Fifteen percent said they spent no additional time with LEP patients.

"The extra time comes with patients taking a longer time to explain symptoms, ask questions and understand health information and treatment," said Board of Regents Chair William E. Golden, MACP. "Health literacy is a challenge as is, and it is made more challenging for patients who speak English as a second language."

The College's survey, conducted in late 2006, found that 54% of those doctors who treat LEP patients see such patients several times a week, and that 39% of the patients are older than 65. All told, internists reported seeing patients who speak nearly 80 languages, with Spanish being the most common.

About two-thirds of practices with LEP patients provide language services, typically via a bilingual physician or staff member. Of these practices, 38% said the services didn't cost them extra money, while 24% estimated the extra annual cost at between $5,000 and $25,000. The estimated average cost across all practices is about $19,000. Most of these costs are for language resources internal to the practice.

A paper summarizing the survey findings can be found online.

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