As I introduced in a previous article, there is an undercurrent occurring in health care today called the Patient-Centered Medical Home (PCMH). The PCMH is intended to carry out what is known as the "triple aim": better patient experience with care, improved quality of care (leading to better health), and reduced costs.1 The PCMH is quickly becoming a foundation upon which our new health care delivery system is being rebuilt, impacting the process of health care delivery at the practice level.
Some of us doctors remember with fondness the days when all we needed was a license to practice. We charged a usual and customary fee billed to a third-party payer. Then managed care came along in the 1990s. Not only did we have to be licensed, but we also were credentialed by a payer or network and had to agree to a contracted fee for our services.
Well, the times are once again changing within the landscape of health care delivery. This transformation, which is occurring literally as you read this article, will require a primary care clinician to operate within a standards-based, recognized practice setting called a medical home. Recognition will follow the completion of organizing the practice's processes based on a set of standards that are patient-centered and incorporates accepted guidelines within its operation.
So, how does all this take place? What do we need to do to get ready? Let's take a look at the first PCMH standard to answer this question – PCMH 1: Enhance Access and Continuity.
Access refers to how readily your patients can access you both during and after office hours for clinical advice and/or treatment. Continuity of care regards the seamless approach to delivering care and clinical advice in a timely manner when the patient needs it – not when it is convenient for the physician.
If you are like my family and me, we grew accustomed to our practice as a lifestyle, not a job. My wife and daughters took turns being with me while I attended to patients in the middle of the night, on weekends and when patients would literally show up on the doorsteps of my home in the evenings. My staff did their best to make sure we saw every patient who called on the same day. I called patients back in a timely manner and followed-up with them after a visit to the specialist or to give them the results of tests. I came to work earlier than my opening time and stayed later than my closing time to accommodate my patients' needs. I have no doubt this describes the lifestyle and work ethic of many chiropractic physicians.
As chiropractors, we take these essential functions of care coordination, collaboration and communication seriously – because as a primary care clinician, we understand this is exactly what is expected of us for the betterment of our patients, a result of patient-centeredness. However, health care delivery in general has not operated along these lines. The PCMH 1 standard requires a written policy for the process that is followed regarding same-day appointments, timely clinical advice by telephone or secure electronic messaging both during and after office hours, as well as documenting this advice in the patient's health record. And it requires you to have it in policy and that you and your staff "walk the talk."
Here are a few questions to test how wide your door is open to clinical access for your patients:
What is your policy for patients receiving clinical advice should you be away on vacation? How will a patient access care during your absence?
If you are a group practice, how are patients assigned a clinician and what is your policy for when their clinician of choice is unavailable?
How often is the patient able to access their clinician of choice?
What is your policy and process for making electronic records available to your patients upon request? How long do they have to wait for the records?
Do you have educational material that describes your policy so the patient understands when and how they can access you for clinical advice?
Does your practice meet the cultural and linguistic needs of your patient population?
Do you and your staff function as a clinical team discussing patient progress, needs, etc.? (I am not talking about the monthly staff meeting here.)
Do you and your staff "huddle" to discuss the care needs of the patients to be seen that day or week? Is your staff trained to help carry out a designated portion of patient care?
Do you have a practice team involved in assessing the practice's performance and how to improve it?
How much time does it take to follow-up with a patient on test results and referrals? What is your policy goal?
Well, how did you do? Do you have a written process addressing each of these? The National Committee on Quality Assurance (NCQA) has laid out guidelines in six key areas for the PCMH. You can access these guidelines at www.ncqa.org.
Keep in mind that the NCQA does not currently include chiropractic physicians within its definition of a primary care clinician. According to the NCQA, an organization that credentials medical homes, a primary care physician is an MD, DO, NP or PA. Nonetheless, the NCQA guidelines are quickly being regarded as the standard for recognizing medical homes – and here is why:
Published and ongoing research on PCMH is growing, not only among states with their Medicaid programs, but also commercial payers. For instance, the outcomes for seven medical demonstrations2 revealed reduced hospitalization rates, reduced ER visits and increased savings per patient. These types of results are being repeated over and over again with demonstration projects and pilot studies. This movement has momentum. But the question we need to ask ourselves is this:
Who will the public and private payers recognize as primary care providers in the new health care marketplace, with the central model being the PCMH? States are beginning to create legislation to define not only the PCMH or "health home," but also the health professional as the "central hub" of the PCMH delivery: the primary care clinician. This creates a dilemma for chiropractic physicians. We need to be on the alert and ready to respond to how these changes impact our practice within the marketplace and as a profession.
Will chiropractic physicians be included in the definition of a primary care clinician? Or will they be defined as a specialist needing a referral from a primary care clinician? Therein illustrates the central concern.
The Patient Protection and Affordable Care Act (PPACA) was merely a start of the changes we are seeing take shape within the health care delivery system. The PPACA was the initiator. And even if for some reason this law goes away, the commercial market has already moved down this path.
It is time to respond to these changes proactively. Reimbursement in the future will become contingent upon the quality of your practice operation and clinical outcomes. There is no time to wait to see if these changes will impact you in your practice – they most certainly will and are. As a profession, we need to strategically prepare ourselves and our practices, and proactively foster a legislative interest in what will become our profession's most defining moment in history.
So, are you getting yourself and your practice prepared? This could be the greatest opportunity for our profession to shine.
References
Taylor EF, Lake T, Nysenbaum J, Peterson G, Meyers D. Coordinating Care in the Medical Neighborhood: Critical Components and Available Mechanisms. White paper prepared by Mathematica Policy Research under Contract No. HHSA290200900019I TO2. AHRQ Publication No. 11-0064. Rockville, MD: Agency for Healthcare Research and Quality, June 2011.
Fields D, Leschen E, Patel K. Driving quality gains and cost savings through adoption of medical homes. Health Affairs, 2010;29(5):819-26.
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