Unless you've been practicing internal medicine under a rock for the past several years, you've probably heard of the patient-centered medical home. But how many internists have actually seen one in action, or better yet, taken the model for a spin?
A group of physicians in southeastern Pennsylvania are among the lucky and proactive few practicing in some of the first payer-supported patient-centered medical homes (PCMH) in the country. Led by Gov. Ed Rendell's Chronic Care Commission, the first phase of the Pennsylvania project includes 32 internal medicine and family practices and six major payers.
The PCMH has been experimented with in several states, including North Carolina, Vermont and Rhode Island, but the Pennsylvania project is unique in its size and structure. Participating practices receive supplemental payments in exchange for providing unusually comprehensive and patient-centered care, especially for patients with chronic disease.
“In 2007, Pennsylvanians spent almost $4 billion on potentially avoidable hospital charges for just four chronic diseases—asthma, diabetes, chronic obstructive pulmonary disease and congestive heart failure,” said Phil Magistro, who directs the program for the Governor's Office of Health Care Reform (GOHCR). “It was obvious that we had to do something.”
What they did, starting in 2007, was to bring several insurers together to discuss how and how much they would be willing to pay for improved chronic care of their patients. It was an unusual kind of meeting, said Mr. Magistro, made possible by the involvement of the governor's office. “Because of anti-trust, payers are never allowed to sit in the same room and talk about what they would pay,” he explained.
However, once protected from potential anti-trust violations, the payers and other interested parties, including ACP, offered input to help GOHCR create a collaborative plan to pay practices for becoming medical homes. The first set of practices in southeastern Pennsylvania embarked on the project in May 2008 and another three regions in the state are rolling it out in early 2009.
“We expect that the combination of resources from the governor's office, payment from the health plans and purchasers, and support from grant-funded programs will result in a fundamental redesign of the participating practices for all patients—leading to higher quality care and greater satisfaction for everyone involved,” said Shari M. Erickson, senior associate in ACP's department of Practice Advocacy and Improvement.
Putting theory into practice
So what did the physicians and their staffs actually have to do to become medical homes? That varied a fair amount from practice to practice, explained Mr. Magistro. The basic requirement of the project was that practices work toward PCMH recognition from the National Committee for Quality Assurance (NCQA) and achieve at least Level 1 certification within a year.
Once practices reached Level 1, they began receiving supplemental payments to help offset their increased costs. With each additional certification, the payment supplement bumped up as well.
Some participating practices were ahead of the game enough at enrollment that they've already reached Level 3 while others are still working to attain Level 1. “The seven that reached Level 3, it would be great if we could take credit for it, but I think they had a pretty big leg up on this,” said Mr. Magistro. But of the 12 practices that had reached Level 1 by eight months in, two were groups that dramatically outperformed expectations—project leaders had worried that they wouldn't make the cut within a year.
All of the practices were given seven days of collaborative learning, patient registries, individual coaching and feedback and many opportunities to consult with colleagues on the project. The instruction and the practices' goals were based on the chronic care model developed by Edward H. Wagner, FACP (more information about the chronic care model is online. “There is pretty robust research supporting the effectiveness of the chronic care model, but nothing's been done of the combined nature and scope of what we're doing,” said Michael Bailit, a consultant on the project.
As one of the Level 3 practices, Ninth Street Internal Medicine was already pretty up-to-date, having had an electronic health record (EHR) in place for two years, said managing partner Allan L. Crimm, ACP Member. But the collaborative made dramatic improvements in the practice's operation, he said. “We had not figured out how to use [the EHR] to transform the clinical part of taking care of patients. All we were doing was changing the way we recorded information.”
In adult practices, the initial focus of the collaborative was on diabetes care (pediatric practices concentrated on asthma). Participants were taught how to use an EHR to pull up lists of all their patients with an A1c over 9, or diabetics who hadn't been seen in more than six months, for example, and then they worked on ways to improve care for these patients.
Changes in the visit
One means of improvement was pre-visit planning. “A day before or two days before [a visit], you look into each patient who has one of those target conditions and say, ‘OK, what do need to do in terms of labs? What do we need to do in terms of vaccinations, examinations?’” said Dr. Crimm.
The practices also streamlined the process of getting the routine aspects of diabetes care—vaccinations, foot exams, etc.—completed in an efficient way. Teamwork, a major component of the Wagner chronic care model, was key to that change. At the learning sessions, each practice was required to send not only a physician but also a nurse and office manager to facilitate the team structure.
“When we changed the way we organized the delivery of service, it's really made a huge difference and it's taken a lot of the burden off physicians. Instead of this just being the heroic work of individual physicians trying to manage each patient, we've evolved to have a system of care where we have standing orders for things the patients need,” Dr. Crimm said. Now, before the patient even sees a doctor, he or she has provided any needed urine samples, received a monofilament exam from a medical assistant or completed other aspects of care that don't require a physician's expertise.
Program leaders encouraged the participating practices to start scheduling entire visits in which patients don't see a doctor, but are treated by a health educator or a nurse practitioner instead. Getting physicians to accept that idea was a challenge in some cases, Mr. Magistro said.
“The doctor shouldn't have to see every patient,” he said. “Some practices adopt that model really easily. Other practices have really automated their processes and are really efficient, but the physician is still totally involved in everything.”
Another core principle of the model was patients' greater involvement in their own care. “We've spent a lot of time working on tools through the EHR and developing ways of structuring the visits so that patients are engaged up front with their care. When they leave, they have more information and an action plan for self-management,” explained Susan C. Day, FACP, of PennCare Internal Medicine, another Level 3 practice.
At the end of every diabetes-related visit, a patient report card prints out automatically so patients can see how they're doing on glucose, blood pressure and other targets. The report cards have been popular with patients and shown success in improving self-care, Dr. Day said.
Take a little time
But it has taken individual effort as well as great computer systems to deal with the problem of patient engagement, noted Richard J. Baron, FACP, whose practice, Greenhouse Internists, also reached Level 3.
“I don't know how to get patients with [an] A1c over 9 that I haven't seen in six months under control. As you start digging into it, some of them have lost their health insurance; some of them are depressed; some of them aren't taking their meds. There are a bunch of reasons,” he said. “We try to identify and address the ones that might be fixable.”
Because physicians often don't have time to dig into and solve all these issues, this is another area where teamwork has been critical, the program participants said. Many of the practices have used the supplemental funding to hire health educators, health coaches, or care managers. Or they've trained current staff to take on new responsibilities.
“We're developing some special visits with our NPs where they have a little bit more time to spend with the patients. We've seen some dramatic improvements in their A1c [levels] with just reaching out and identifying barriers, some financial and some transportation,” said Dr. Day.
Observed improvements in care measures and enthusiasm from patients, physicians and staff have made the program participants firm believers in the PCMH. “It's been a much more pleasurable relationship with patients because the locus of control is given back to the patients,” said Dr. Crimm. Of course, the expectation is that the program will also reduce health care costs, thus justifying the supplemental payments made by the insurers.
Under the southeastern program, participating insurers made supplemental payments based on the percentage of a practice's revenue that their insureds represent, and the size of the supplements increased with attainment of higher NCQA recognition. “We have almost a 15% gross revenue increase flowing in as a result of this,” noted Dr. Baron. Payment incentives are structured somewhat differently in each of the Pennsylvania regions, but for the southeastern docs at least, the finances worked out positively.
Will it show the money?
The participating physicians expressed confidence both that the collaborative would be a money-saver and that the insurers' financial investment was crucial to its success. “It doesn't take very many diabetic patients who don't have foot amputations or strokes because you got their blood pressure and cholesterol under control and they started wearing molded shoes to make a difference in terms of aggregate health care dollars,” said Dr. Crimm.
Some but not all of the improvements could be implemented even without the support of a collaborative, the doctors noted. For example, teaching medical assistants to do monofilaments was one of the best things he did, Dr. Crimm said, and the system can be instituted gradually, beginning with one medical assistant and a couple of patients.
“The question is whether if you just get an electronic record and increase efficiency, you'll be able to accomplish the same goals,” said Dr. Day. “But our experience has been that we're talking about changing how office staff, including the physicians, spend their time, and developing different skill sets. Otherwise, the emphasis of practice continues to be on getting as many patients through as quickly as possible and staying on time, and you won't add these additional services.”
The program also helped physicians and insurers get out of the hostile dynamic that often frames their interactions, according to Dr. Baron. “The professional response has been, ‘I can't do all those things because you don't pay me.’ The other response is ‘I'm already doing those things but you don't pay me.’ Neither are really true: we need new primary care models to justify new payment. This is a pathway out of that sterile conversation,” he said.
How far the new Pennsylvania pathway can go will be determined over the next couple of years. In addition to the monthly reports filed by the practices, the project as a whole will be evaluated on quality and cost measures after 18 and 36 months. After 36 months, the insurers' commitment to the supplemental payments will end but program proponents hope the improvement and innovation will continue.
“Between now and then, our challenge is to work with either existing pay-for-performance packages and define common measures to be implemented across payers, or to take on payment reform, or in some way make the whole primary care reimbursement a sustainable revenue system for the practices that have changed,” said Mr. Magistro.
It may sound like a lofty goal, but perhaps not too much for the group that's already brought insurers, providers and the government together as a team to improve care for chronically ill patients.