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Saturday, October 17, 2009

Ten steps from ordinary practice to PCMH practice?

This new article from FPM says the trick is to start with steps that increase practice revenue, then use that revenue to support later steps.

  • First, stop undercoding; get the revenue you deserve.

  • Second, use the revenue to hire more nurses or MAs.

  • Third, increase your productivity and revenue by offloading work onto your newly enlarged support staff.

  • Fourth, ... well, why not read the article?

Friday, October 16, 2009

Beyond PCMH: Is your practice an "accountable care organization"?

The patient-centered medical home model, which has been in the spotlight over the last few years, may soon have to share the stage with a new model: the "accountable care organization."

What's an accountable care organization? According to a recent report from Harold Miller, executive director of the Center for Health Care Quality and Payment Reform, an accountable care organization is "a health care provider or group of providers that accepts accountability for the total cost of care received by a population."

What does a practice need in order to act as an accountable care organization? Miller identifies eight elements:

  1. Complete and timely information (including cost information) about your patients and the services they are receiving. Miller notes that most practices will need "significant assistance" from payers in order to obtain this information.
  2. Technology and skills for population management and coordination of care, such as using clinical guidelines and monitoring compliance with them, analyzing data on resource use and utilizing a patient registry.
  3. Adequate resources for patient education and self-management support.
  4. A culture of teamwork among the staff of the practice.
  5. Coordinated relationships with specialists and other providers.
  6. The ability to measure and report on the quality of care.
  7. Infrastructure and skills for management of financial risk.
  8. A commitment by the organization’s leadership to improve value and create operational accountability.

How does an accountable care organization differ from a patient-centered medical home? According to Miller, "Most initiatives today to help primary care practices become Medical Homes do not require that the primary care practice accept any accountability for the total costs of care for their patients or for population-level quality outcomes. Even though many of the enhanced resources and tools being developed and used by Medical Homes, such as electronic health records, patient registries, patient education on chronic disease management, and more responsive scheduling, could help improve quality and reduce total costs, there is no guarantee that they will do so unless the primary care practice actually focuses on improving those outcomes as an explicit goal and uses the medical home tools to achieve the goal. Indeed, the Congressional Budget Office, in evaluating various health delivery reform options, estimated that paying for Medical Homes for chronically ill beneficiaries in Medicare would increase spending by $5.6 billion, rather than reduce costs."

Miller continues, "This implies that while becoming a Medical Home could help a primary care practice become an Accountable Care Organization, it is not sufficient. Conversely, in order to function effectively as an Accountable Care Organization, it may not be necessary for a primary care practice to meet all of the detailed standards that organizations such as the National Committee for Quality Assurance (NCQA) require of primary care practices in order to be formally designated as a 'Patient-Centered Medical Home.' Indeed, detailed accreditation standards are being used in medical home programs partly because payers are concerned about whether making higher payments to primary care practices to enable them to serve as medical homes will actually result in improved outcomes for patients and lower costs for payers. Since there is not strong evidence that all of the structural and process standards established for medical homes are necessary for improved patient outcomes and some may be difficult or expensive for practices to achieve, and because some practices that would not meet these standards have been successful in proactively managing and coordinating their patients’ care, a primary care practice should not be precluded from serving as an Accountable Care Organization simply because it has not met accreditation standards as a Medical Home."

Thursday, October 8, 2009

Is your practice a medical home?

From NPR.org:

"Insurers will also pay [practices participating in a medical home pilot project] bonuses for keeping patients healthy. So, behind the scenes, the office is keeping track of patients, especially if they have a condition such as diabetes or asthma. Dr. Paul Grundy, the founder of a group that's promoting medical homes, says some doctors tell him they already do all that. 'One of the first questions I ask them is, Do you know every single woman in your practice [who is] over 50 and the status of her breast exams? And do you know every man who is over 55 and the status of his colonoscopy exams? If you don't, you don't have a medical home ...'"

Click here to read about the AAFP's definition of a patient-centered medical home.

Friday, October 2, 2009

Medicare's medical home demonstration project: Old news?

A recent press release from the Department of Health and Human Services (HHS) announcing plans for a demonstration project designed around "Advanced Primary Care models" left us, and perhaps many of you, with two big questions: What is the status of the much-anticipated and long-delayed Medicare medical home demonstration project? What is an Advanced Primary Care model? We now have at least partial answers to these questions.

The Medicare medical home demonstration project is at least briefly mentioned in a fact sheet that describes the newer initiative: "CMS will move forward with a separate Medical Home Demonstration required under the Medicare Improvements for Patients and Providers Act (MIPPA) and the Tax Relief & Health Care Act of 2006 (TRHCA)." But the time frame for the project remains unclear. The original schedule called for the Centers for Medicare & Medicaid Services (CMS) to announce in December 2008 the states where the demonstration would be conducted. The application and qualification processes were to have played out this year, and payments to participating practices were to have begun in January 2010. James Coan, a CMS project officer, said in the spring that the eight states have been selected, but CMS is still awaiting approval from the White House Office of Management and Budget to move forward with the project. That approval was first expected nearly a year ago.

The HHS fact sheet says the Advanced Primary Care model that the new project is designed to test is "also known as the patient-centered medical home." The reason for the new term will have to be the subject of a future blog post, but here's what we do know: The project will build on a model being tested in Vermont, where private insurers and the state's Medicaid program are collaborating to develop standards and compensation incentives for primary care physicians. The demonstration project will create opportunities for Medicare to join in similar efforts. Application materials will be developed this fall with the expectation that the demonstration projects will begin in 2010, according to the release. Nancy-Ann DeParle, director of the White House Office of Health Reform, called the project "a jump start on health insurance reform." Given the uncertainty surrounding the Medicare medical home demonstration, you have to wonder whether government health programs are capable of such a thing.

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