Challenges, Hope for Small Practices and PCMH
One of the interesting things AAFP Board members get to do is travel to state chapter meetings. This is a great experience because we get to hear the issues that concern our members from across the nation.
One question that has been posed to me multiple times at such meetings regards the challenges small practices face in transforming to the patient-centered medical home (PCMH) model.
There are volumes of data supporting the transformation to a value-based, rather than a volume-based, system. The change results in better patient health outcomes at lower health care costs. Unfortunately, however, most of the available data comes from large practices, and the costs involved in making the transformation often are covered by higher level evaluation and management (E/M) coding, as well as shared savings from reduced emergency room and hospital expenses.
The hope of a blended payment system is on the horizon, but it isn't incorporated yet in most markets. Small practices often don't have the internal support to make the transformation and often don't get the advantage of lower overall health care costs.
The question frequently posed to me is, does transformation make sense for the small practice?
Some small practices have made the transformation and reaped the benefits. But some have suffered financial ruin when trying to make the change. One member told me she had to close her solo practice after moving to the PCMH model. After starting her electronic health record (EHR) and making adjustments to make her practice a PCMH, she went bankrupt. Although she was able to charge more per visit in the new practice model, her visits took longer so she saw fewer patients.
She was not able to collect on the patient portal encounters through insurance. Visits by her nurse and nutritionist were not well compensated. After 20 years in practice, she closed her doors and went to work for a large multidisciplinary group in another town. Now she is away from home 20 days a month and is not happy with the change.
My own residency practice had issues as well. We did not have insurance support paying for some of the PCMH attributes, and the higher E/M charges did not outweigh the longer patient visits. We ended up going back to a volume-based system to survive.
What about the bigger picture? Thirty-eight percent of AAFP members practice in groups of fewer than four providers. There is no data available to tell us how many of these practices have transformed to the PCMH model, but we do know that 57 percent of our small practices have started implementing EHRs, which might be the first step to PCMH recognition. Conversely, 85 percent of our large practices have converted to EHRs, so it seems that those larger practices may have more infrastructure in place to support change.
One of the four strategic priorities of the AAFP is practice enhancement. One of the main goals of this area is the transformation of all family medicine practices to the PCMH model. Another priority in practice enhancement is improved payment for family physicians. It is difficult to separate these two issues because to transform one's practice, it costs both time and money. Our Academy realizes this and is advocating for better payment for primary care and even enhanced payment for those who offer the attributes of a PCMH. The eventual goal would be to have a blended payment system that would incorporate a per-member, per-month base fee plus a fee-for-service payment and a pay-for-performance payment.
The Congress of Delegates asked the AAFP to study the impact of PCMH transformation on small practices last year, and a study on the topic was published earlier this year in Annals of Family Medicine. However, only practices that have achieved National Committee for Quality Assurance recognition were included in the study, which acknowledged small practices that have achieved recognition did so as part of local demonstration projects or with help from financial incentives or other support.
What about practices that are attempting transformation without the benefit of a demonstration project or grants? And what about small practices that have attempted practice transformation but were not, or have not yet been, successful? What has stopped them, and what could make a difference?
Clearly, we need more research on practice transformation and the barriers that small practices face.
The overall cost to transform a practice from a standard, paper-based practice to a PCMH with an EHR is roughly $100,000 per full-time equivalent physician overall. But is this true for small practices? Is the cost more or less? When overall health care costs decline, are the savings shared with the small practice providers?
Do the better health care outcomes seen in large PCMHs translate to small practices? It would seem so, but the evidence is lacking.
So, is there hope for small practices that want to transform to PCMH? The answer is yes.
TransforMED, the AAFP's wholly owned, nonprofit subsidiary, was created in response to the Future of Family Medicine Project to help practices make the transition to the PCMH model, but initial efforts to engage small practices met with little success. The reality is that many small practices lacked the necessary capital to invest in practice transformation, and some did not value consultant services.
The market imperative for TransforMED was to serve health plans, multi-specialty groups and integrated systems because they had the money and the understanding that change facilitation was needed to accomplish this work. As a result of its commercial success, TransforMED has grown and now offers small practices access to information, expert advice and tools on DeltaExchange, which is free to AAFP members.
Many of the changes required for PCMH have to do with organization and workflow and may not be expensive to implement. Small practices can begin the transformation while still in a fee-for-service environment, but the real change will be accelerated when blended payment, global payment and payment for value become the norm.
The Academy soon will offer another resource that will help members transform their practices. The PCMH Planner, which likely will be launched early in 2014, was promoted and available for a "sneak preview" during Scientific Assembly last week in San Diego. The Planner is an online software subscription tool that will help practices assess their needs and provide them with step-by-step guides and links to resources to help them complete PCMH transformation and achieve meaningful use. AAFP members will receive a discounted price when they subscribe to the tool.
As a member benefit, the Academy's Division of Practice Advancement also has subject matter experts available to answer questions about PCMH and provide free resources on the topic. You can connect with them through the AAFP Contact Center at (800) 274-2237.
Finally, last week in San Diego, the Congress of Delegates adopted a resolution that calls for the AAFP to study EHR adoption and PCMH transformation by family physicians who may face additional barriers to change -- including age, practice size and rural location -- and determine the best ways to help them stay in practice.
The Congress of Delegates also referred to the Board of Directors two resolutions that asked the Academy to form a special interest group devoted to physicians in solo or small-group practices. The Academy already has a task force -- chaired by AAFP President Reid Blackwelder, M.D. -- working to determine how best to serve the needs of specific membership groups. That task force met last month and is scheduled to meet again early next year.
I would be interested in your comments about PCMH implementation for small practices and what more the Academy can do to help. Also, it would be interesting to know about small practices that have successfully transformed to a PCMH and how you were able to do it, so we could share best practices with other members.
Daniel Spogen, M.D., is a member of the AAFP Board of Directors.
Relationships Are a Critical Part of Building Medical Homes
The small Nebraska town where I practice family medicine has a population of about 2,000. Although my practice is only 30 minutes west of Lincoln -- the state's capital and second-largest city -- solo and small family practices are common in the rural areas to my north, south and west.
As my colleagues in these small practices ponder the patient-centered medical home (PCMH), I know that it can seem overwhelming to implement. The bodies that recognize or certify PCMH practices have numerous confusing requirements that have more to do with processes than patient care. So when I talk to family physicians who have concerns about the PCMH, I suggest they read the original articles on the subject by Barbara Starfield, M.D., M.P.H.
Instead of a large number of boxes to check, Starfield thought there were three simple things at the core of becoming a medical home.
The first is to be comprehensive in your approach to health care. It is comprehensiveness that separates us from our subspecialty colleagues who focus on a single organ system or a single disease entity. It is comprehensiveness that separates us from midlevel providers who say they can deliver care as well or better than family physicians. Ordering more tests and referring to subspecialists is not comprehensive care. Family medicine is.
The second critical factor is disease management. We all know there are certain diagnoses that predispose patients to increased morbidity and mortality. The Academy has clinical recommendations and resources to help your practice with chronic disease management protocols that fit your practice. You also can develop disease registries to be more proactive with these patients. By doing so, we can reduce morbidity and mortality and ultimately reduce costs to our health care system.
Finally, relationships and continuity of care are important. Knowing our patients and their families facilitates caring for them. This can reduce duplication of tests and improve compliance to treatment plans by understanding each patient's culture and concerns. I recently had this brought home to me by one of my long-time patients.
Oliver was a 92-year-old, retired minister who had contracted pneumonia and required hospitalization. I have cared for his family for years. In fact, I delivered two of his grandsons.
Oliver was not responding to treatment, so as I examined him, I talked to his family -- including those grandsons -- about other interventions we could try to improve his situation. As I talked, his son, David, got out of his chair, came to me and placed his hand on my arm. He said, "Dr. Wergin, you know my dad loves you, and we all love you. You are as much a part of our family as anyone in this room. We wanted to let you know that my father does not fear death and is ready for what's to come. In fact, we are all ready for what's to come, but we're worried about you. You don't seem to be ready."
I looked at David and told him I understood. I went to the nurse's station and wrote a prescription for morphine and other comfort measures. I continued to round on him and talk to him each day. There was no new hospice nurse or shift-working hospitalist. Instead, it was just me and Oliver's family. That's family medicine.
Oliver passed away a few days later. It was a quiet death, and his family members were with him.
Medicine is always changing, and we have to be prepared. It is important to develop a plan to meet PCMH requirements if you want to be recognized or certified as a PCMH practice. We know that our strict fee-for-service model, which has not served us well, is coming to an end. To be reimbursed in a new model of payment, we must show we deliver what we promise. Don't be discouraged, and remember that patient-centered care is based on these three things: comprehensiveness, disease management and relationships.
How do you build relationships with your patients?
Robert Wergin, M.D., is a member of the AAFP Board of Directors.
Teamwork Key to Improving Quality of Care
I've been interested in the patient-centered medical home (PCMH) since the Future of Family Medicine report recommended that every American should have a medical home back in 2004. I was on the AAFP's Commission on Practice Enhancement (now the Commission on Quality and Practice) from 2006-2010, and the concept was a hot topic for our commission.
When my multi-specialty medical group in New Mexico
decided to implement the PCMH in our own clinics, I served on an advisory
committee that helped make it happen. When it was time to implement electronic
health records (EHRs), my clinic was the guinea pig. We got our EHR up and
running before the system was rolled out to the whole group. Today, all 10 of
our primary care clinics have achieved National Committee for Quality Assurance
Level 3 PCMH recognition.
Although teamwork was critical to the progress we made as a larger organization, looking back I realized we hadn't done enough team building in our own clinic. So beginning in 2011, we worked to improve our practice -- which has 30 employees, including three physicians and three nurse practitioners -- by establishing a high-functioning team dedicated to addressing issues specific to certain diseases, conditions or issues.
We didn't dive right in. It was a deliberate process. We spent six months carefully crafting mission and vision statements and setting goals and objectives.
It might sound like slow going, but it was worth it. Our staff members -- both clinical and office -- now own the concept of working together and are invested in it. We believe in it, and that's huge.
Every Monday morning, we meet to review a list of objectives and select new projects to begin. We have made some significant strides, but quality improvement never ends.
Our diabetes team started with a simple project to become familiar with the process of foot exams. Physicians and nurses, me included, were not consistently performing foot exams for every patient with diabetes. And when they were being performed, the results were not consistently recorded in the right place in our EHR. Our team devised new protocols to ensure that the exams are performed and recorded in a consistent, retrievable manner.
Our pain management team extensively reviewed the new state regulations for opioid prescribing and monitoring to make sure patient agreements are signed and that regular screenings are performed. We added several instruments to our EHR and made it easy for everyone to learn and use them. Now, every patient on long-term opioids has a signed agreement, documentation on a statewide database, periodic urine drug screening and a treatment plan.
Some projects are more complex. One team is working toward a goal of having every patient in our practice aged 18 years and older have an advance directive. They are establishing a process to introduce the concept to patients and to follow up and ensure forms are returned. It's not an easy task. But after surveys, training and EHR modification, the process is poised to encourage and track patients' use of the advance directive at whatever level they deem appropriate with our guidance. Our method has been spread to our other primary care clinics, making it easier to approach this sensitive subject.
The work we've done is a step beyond what PCMH recognition calls for, but this is what the PCMH truly is about. It has resulted in better care for patients and more satisfying work for employees. Team building has been a very rewarding process, with no end in sight. It is the future because it is continuous quality improvement that is now part of our clinic culture.
What team work successes have you experienced on your road to PCMH transformation?
Richard Madden, M.D., is a member of the AAFP Board of Directors.
Residencies Face Barriers to Teaching PCMH
I believe that the patient-centered medical home (PCMH) is the future of primary care. The model has been proven to provide cost effective and high quality health care, and some payers are beginning to recognize its value.
At the University of Nevada School of Medicine, where I am chair of the department of family medicine, we have developed curriculum for students that includes required reading, faculty lectures and shadowing faculty. It's working out well for student education.
But in Nevada, and elsewhere, teaching the PCMH model to residents remains an issue that needs a solution. It's a looming problem for residencies because, starting in 2015, the Accreditation Council for Graduate Medical Education (ACGME) will require residencies to teach population management. Although population management sounds big and broad, the reality is that PCMH is the most likely model to fill that accreditation requirement.
According to an estimate by the Association of Departments of Family Medicine (ADFM), one-third of residencies already are teaching PCMH, one-third are working to implement it into their training programs and one-third have made no progress in implementing it.
That leaves many programs with a lot of work to do in the next two years. Unfortunately, adding curriculum with no new resources amounts to an unfunded mandate. How will these programs adjust?
The good news is that help may be on the way. For years, the AAFP, and a coalition of other primary care groups, has been urging the Health Resources and Services Administration (HRSA) to study the development of PCMH curriculum in primary care residencies. A pilot project, funded by HRSA, is expected to start this spring at four universities (encompassing a total of 12 pediatric, family medicine and internal medicine residencies).
The goal will be to develop a unified curriculum that could be deployed in any of our nation's roughly 1,000 primary care residency programs.
Of course, the lack of standardized curriculum is just one barrier to making a residency program a PCMH. Population management is impossible without a robust electronic health record (EHR) system, and some programs just aren't there yet.
It's estimated that implementing an EHR in private practice costs roughly $80,000 per full-time equivalent physician. Here in Nevada, we have six departments in Las Vegas and four in Reno. The cost to implement our new EHR is estimated at $6 million. For some training programs, the cost will be even higher.
Grant money has helped some residency programs move forward with EHR implementation, but others lack the resources to take that step, which is a shame because the PCMH is good for patients. It stresses preventive care, engages the patient and encourages a healthy lifestyle. It also benefits payers by lowering costs, improving care and leading to better outcomes.
We can talk to our residents about PCMH, and we can teach them about things such as team-based care. But without an established curriculum and robust EHRs, residents are only getting a taste of what the PCMH is all about.
And those who don't learn the PCMH in residency will be forced to learn it as new physicians. Surely, there is a better way. We need a consistent method of teaching PCMH at all levels of education.
Payers stand to reap the benefits of physicians who practice in the PCMH model. So payers should recognize that teaching students and residents in this model is costly and do what they can to help facilitate that training.
Application Deadline Approaching for Pilot Program to Increase Primary Care Payment
Some primary care physicians have understandably taken a "show-me-the-money" approach to the patient-centered medical home (PCMH). They want to know that the investment is going to be worth the considerable time, effort and -- of course -- money before implementing the PCMH model.
trailblazers who believe in this model and already are transforming their
practices stand prepared to reap the benefits in seven select markets when CMS
puts the patient-centered model to the test in its Comprehensive Primary
Care Initiative. But time is
short. The deadline to apply is July 20.
Although the CPC Initiative will affect our members in only seven specific areas initially, it could have far-reaching effects on the future of our specialty. Once CMS is able to show that the initiative meets the triple aim of providing better health and better care at a lower cost, HHS has the discretion to expand the program more broadly.
In short, if this succeeds for practices and payers in the test markets, we all stand to benefit.
So will the CPC Initiative actually show us the money?
CMS is offering a well-outlined program for these markets and has provided clear guidance on what participating practices will receive for Medicare patients.
- CMS will offer a blended payment model that combines fee-for-service with a per-patient, per-month care coordination fee ranging from $8 to $40 with an average of $20. Participating private payers also will offer their own per-patient, per-month fees. Medicaid also is participating in some markets.
- Participating private payers also may offer their own per-patient, per-month care management fees and /or other care coordination support services.
- Participating practices also have an opportunity to participate in shared savings with both public and private payers.
The initiative seeks to foster collaboration between public and private payers to strengthen primary care with 45 commercial, federal and state insurers participating in selected markets. I urge practices in the following selected markets to complete a brief screening tool.
- Arkansas (statewide),
- Colorado (statewide),
- New Jersey (statewide),
- New York (Capital District-Hudson Valley region),
- Ohio (Cincinnati-Dayton region),
- Oklahoma (Greater Tulsa region), and
- Oregon (statewide).
Practices that meet eligibility criteria will receive an e-mail from CMS with the full application.
Up to 75 practices in each market will be selected to participate. As of July 9, more than 75 practices had started the application process in Arkansas, Colorado, New Jersey and Ohio, but only a fraction of those practices had completed the application. In both Oklahoma and Oregon, roughly 50 practices had started the application process, but only two had completed the application in Oregon and none had completed it in Oklahoma.
This program has too much potential for us to let it pass by. We must seize this opportunity. For more information, including webinars and other resources, check out our CPC Initiative webpage.
Glen Stream, M.D., M.B.I., is president of the AAFP.
It's Simple: Primary Care Equals Better Care Overall
"A strong primary care foundation is critical to improving care for vulnerable populations and to achieving high performance in the U.S. health care system overall. … Access to primary care is associated with improved quality of care, better health outcomes, and lower health care costs."
Sounds good, right? Maybe even familiar. Those sentences echo what the AAFP has been telling Congress, HHS and private payers for years. But that paragraph isn't copied from testimony the Academy provided to Congress or comments we provided to HHS.
Those statements are from the findings of a recent report by The Commonwealth Fund, a private foundation that supports independent research on health care issues.
A previous Commonwealth Fund study found that access to a medical home reduces health disparities for racial and ethnic minorities. This new report builds on that by looking at how health care improves when patients have both health insurance and a medical home.
The results in the most recent report weren't surprising. We already knew access to primary care improves management of chronic illness and averts more complicated problems through better wellness and prevention care. One of the advantages of the medical home model is practices don't wait for patients to show up with a problem. Instead, they take responsibility for keeping patients up to date and notify them when they are due for preventive services or chronic illness care.
According to the Commonwealth Fund report researchers, who surveyed more than 4,000 adult patients, four characteristics were identified as part of a medical home:
- patients had a regular physician or place of care;
- patients experienced no difficulty contacting their physician by phone;
- patients believed their physician knew their medical history; and
- patients said their physicians coordinate care with other doctors.
By that definition, fewer than half of U.S. adults have medical homes. So how much of a difference do insurance and a medical home actually make? According to the Commonwealth Fund report:
- 95 percent of insured adults reported having a primary care physician, compared to fewer than 75 percent of uninsured adults;
- more than half of insured adults had a medical home, compared to 27 percent of uninsured adults;
- more than half of insured, nonelderly adults were up to date on recommended preventive screenings, compared to a little more than one-third of those without health insurance;
- more than half of low-income adults with health insurance and a medical home reported receiving all recommended preventive screenings, compared with 44 percent of respondents without a medical home;
- among low-income adults with health insurance, only 35 percent of respondents with a medical home reported having cost-related access problems, compared with half of respondents without a medical home; and
- nearly two-thirds of adults without health insurance said they had failed to seek medical care because of costs, compared with one-third of insured adults.
The report stressed that its findings affirm the importance of the Patient Protection and Affordable Care Act, which is expected to expand insurance coverage to more than 30 million adults by 2020. The ACA also promotes the adoption of the medical home and other innovative health care delivery models.
A Supreme Court ruling on the health care reform law is expected before the court adjourns at the end of the month
A recent report about Medicare and Medicaid in Health Affairs found that increases in both the availability of acute care beds in a community and the number of physicians per thousand residents were associated with increased health care spending. Conversely, increases in the percentage of physicians working in primary care were associated with reduced spending.
And that brings us back to where we started. Improving access to primary care improves care and outcomes and lowers costs. It's that simple.
Glen Stream, M.D., M.B.I., is president of the AAFP.
Working With Others Key to Successfully Transforming Our Practices
Good partners can make all the difference when transforming a practice.
For example, one of the family physicians in my practice, Andrew Drabick, M.D., was so concerned about the obesity problem in our community that he led our efforts to open a weight loss clinic. Many of our patients found the extra help they needed, and we added an important revenue stream.
One of my other partners, Stephen Moore, M.D., is passionate about practicing family medicine, but he has little desire to be involved in the business of medicine. Stephen puts his trust in others to make sure we are running a sound business. I also love being a family physician, but I have the interest in business that my partner lacks. Together, we provide balance to a practice that has expanded three times in a little more than five years.
We not only have doubled the physical size of the practice, we grew from three physicians and one nurse practitioner to five physicians, two nurse practitioners, one physician assistant and a dietician, as well as an athletic trainer who works with us on a contract basis and a massage therapist who rents space from us.
However, our partners aren't limited to those who work in our office. We've succeeded in improving and transforming our practice because we've been willing to branch out, reach out and find like-minded people who are willing to help us lower our costs while improving care.
One example is the independent practice association (IPA) we've belonged to for more than a decade. The IPA represents about 145 physicians from nearly 50 practices. Members learn best practices from each other, which makes us more efficient and helps us improve outcomes.
Two years ago, the IPA mandated that by the end of 2011, every participating practice had to reach National Committee for Quality Assurance (NCQA) Level 2 or 3 patient-centered medical home (PCMH) recognition. Amazingly, the IPA group lost only three practices, added four new ones and has others interested in joining.
Our practice achieved NCQA Level 3 recognition in 2010. It wasn't easy, but being a member of the IPA made a difference. The organization used funds from member dues and pay-for-performance funds to hire a consultant who helped practices with paperwork related to the process.
Our commitment to the PCMH model already is paying off. Blue Cross and Blue Shield of North Carolina, which covers half our patient population, offers higher fee-for-service payments to primary care physicians who provide patient-centered care. Practices must meet certain criteria, including NCQA recognition.
Due to the IPA’s successes and data proving we help control costs, other businesses and insurers have approached us as well. These opportunities have tremendous potential.
Some physicians are overwhelmed by the thought of the work and investment practice transformation requires. For my practice, it was worth it. Thanks in part to Blue Cross, we experienced more than a 10 percent increase in revenue last year with no significant increase in patient volume. After having almost $2 million in collections in 2010, that 10 percent increase was significant.
We owe some of our success with Blue Cross to yet another partnership -- our involvement with the North Carolina AFP. Our state chapter has been communicating with the health plan for years about the value of primary care. BCBS is starting to get the message and responding with improved payments.
Though individual FPs might not know the key contacts of a state health plan, your state chapter likely does. They are great resources.
Help is there, if you know where to look. The Academy has numerous resources available, and the AAFP and its wholly-owned subsidiary TransforMED recently made Delta Exchange -- a social networking resource focused on practice transformation -- free to Academy members.
The bottom line is that you don't have to go through practice transformation alone. By partnering with the right people and getting the right pieces in place -- both inside and outside of your practice -- you can learn how to make your practice more efficient, more profitable and more enjoyable.
The business of medicine is changing. Are you?
Conrad Flick, M.D., of Cary, N.C., is a third-year member of the AAFP Board of Directors.
New Member Benefit Delta-Exchange Can Help Practices Transform to PCMHs
Talk about good timing.
As family physicians are being presented with opportunities to participate in programs that test new payment models based on the patient-centered medical home (PCMH), the AAFP and TransforMED -- the Academy's wholly owned subsidiary -- are making a new member benefit available to help transform your practices.
When it launched three years ago, TransforMED's Delta-Exchange service was a fee-based, social networking resource where participants could exchange stories and ask questions about transforming their practices to medical homes.
Since then, more than 3,500 medical professionals have registered for Delta-Exchange and are using it to:
- access PCMH best practices,
- ask questions of their colleagues or TransforMED's expert staff;
- connect with other physicians who are transforming their practices; and
- share their own success stories.
Now, this very successful networking opportunity is available to AAFP members as a free service that is a part of their membership in the Academy.
Now that the service is an AAFP member benefit, the number of Delta-Exchange users is expected to grow exponentially now that the service is a member benefit, so there will be even more of your colleagues online who you can connect with to talk about practice transformation.
Delta-Exchange also is a starting point for physicians who hope to participate in programs such as the Comprehensive Primary Care Initiative (CPCI) that CMS announced in September. Participation in that program -- which will blend fee-for-service payments with a risk-adjusted per-patient, per-month care-coordination fee and offer practices an opportunity to share in savings resulting from the CPCI -- will be limited to about 70 practices in each of the seven health care markets selected to be part of the pilot project.
To be considered for the CPCI -- and other programs that test alternative payment models -- physicians will need to demonstrate that they already are working on practice transformation. Delta-Exchange can help you be prepared when these types of opportunities knock.
And Delta-Exchange isn't the only free service the AAFP and TransforMED are offering. As a member of Delta Exchange, you will have access to a series of webinars that TransforMED and the AAFP are offering throughout the year. These webinars will provide information on a variety of practice transformation topics.