July 13, 2016

The Empowered Patient, Part II

Mary MahoneyBY Mary Mahoney

J. Robinson Group Blog

This three-part series explores a big shift in health care: the empowered patient and new models of medical care. Part I explained how changes in the health-care system are gathering momentum. This part explains the concept of the medical home, the challenges it faces and other new models for care and payment.  Part III will look at how physician practices are catching up to the digital age.

Patients in Waiting Room

So your doctor’s office is now called a “medical home.” You are receiving coordinated, patient-centered care. Your primary-care practitioner has received the PCMH-NCQA seal of approval. No, that’s not you? You are not alone. These much-ballyhooed concepts of modern medicine have yet to become mainstream.

The revolution in heath care that started with the Affordable Care Act is just reaching hospitals and private practices. They are beginning to undergo a major transformation, but it’s so difficult to bring about change on a national scale that it isn’t happening consistently. Consequently, most patients haven’t noticed the change.

A confluence of factors brought about this need for change:

  • Doctors’ pay is dwindling because of the fee-for-service model.
  • Many people think they can diagnose and treat their health problems by looking on the internet.
  • Medicare and Medicaid are saddled with escalating medical costs.
  • Hospitals must find new sources of revenue to replace reimbursement cutbacks by health insurers, Medicaid and Medicare.
  • Patients are shuttled from specialist to specialist, test to test, with no single doctor looking at the big picture.
  • The elderly and millions of patients with multiple or chronic conditions are falling through the cracks.

Pouring more money into the system doesn’t seem to be the answer. The U.S. spends 50 percent more on health care than the second-biggest spender, France, and twice as much as the U.K., with no discernible benefit. American lifespans are shorter than some other developed countries, according to commonwealthfund.org.

The Centers for Medicare & Medicaid Services website states, “U.S. health-care spending grew 5.3 percent in 2014, reaching $3.0 trillion, or $9,523 per person.” Projected increases to 2024 are 5.8 percent per year, every year.” Cost has reached a breaking point.

Enter the concept of the patient-centered medical home. As the name implies, it is a place where all patient health-care needs will met, including the desire to participate actively in one’s own care. Primary care physicians will be the point of contact.

The medical home concept was created by pediatricians in 1967. The American Academy of Pediatrics stated that its goal was to have a central location for archiving medical records, especially for children with complex needs.

As explained by the U.S. Department of Health and Human Services, “The patient/family is the focal point of this model.” Now, any primary care practice, or PCP, can convert to a patient-centered medical home, or PCMH.

Going from PCP to PCMH means transforming the patient-doctor relationship from curing illnesses to addressing the needs of “the whole person.” Under this philosophy, care is to be comprehensive, meaning the primary care physician must coordinate with specialists, hospitals, testing facilities and home health, behavioral health and other health-care providers.

Moreover, there should be “better, faster access to care, and a systems-based approach so that data can be analyzed and comprehensive, consistent strategies put into place:” accessible, continuous, comprehensive, family-centered, coordinated, compassionate and culturally effective care.

Easier said than done: A Health and Human Services white paper on adults with complex care challenges explains that the transformation from a typical doctor’s practice to a patient-centered medical home involves many challenges, notably:

  • 78 percent of practices have fewer than five physicians, so there is no economy of scale.
  • How doctors are paid affects how care is delivered, and the current system pays for tests and each service performed, not time spent with the patient or the patient’s other doctors.
  • Primary care physicians have limited specialized knowledge, and their attention may be diverted by daily emergencies.
  • The health and social service systems often have separate and distinct financing streams, delivery systems, professional training programs, eligibility rules and terminology.

Indeed, the American Academy of Family Physicians’ National Demonstration Project, one of the largest efforts to assist primary care physicians with the transition to PCMH, showed that even practices supported by transformation facilitators were unable to put all of the basic components of a medical home into place during the two-year demonstration. “Virtually all practices had difficulty integrating with community services or working in teams,” the project noted.

Some of the recommendations include utilizing case managers instead of medical doctors to coordinate care; reorganizing workflow and systems; offering 24/7 call lines; implementing web-based health information technology registries; and developing referral tracking systems.

The Patient-Centered Primary Care Collaborative puts forth the following principles for medical homes: Care for all stages of life; acute care; chronic care; preventive services; and end of life care. Medical homes also should take responsibility for arranging appropriate care, if needed, by outside qualified professionals.

In those homes, the organization said, “Patients actively participate in decision-making, and feedback is sought to ensure patients’ expectations are being met. Physicians should share in savings from reduced hospitalizations associated with physician-guided care management in the office settings as well as receive additional payments for achieving measurable and continuous quality improvements.”

This is nothing short of a wholesale transformation of the traditional primary care provider model, both philosophically and in how they do business. Time will tell whether such a big change is really feasible and whether patients will benefit.

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