Part 1: The patient-centered medical home

Where does the internist-endocrinologist fit in?

Practice support of the cognitive specialty of endocrinology in the current U.S. fee-for-service environment is usually achieved through a combination of high-volume patient throughput, the performance of office-based procedures and office-based lab testing. The private office may combine all three of these elements where the local environment does not limit reimbursement by restricting payment of some of the office procedures to other specialists such as radiology for DXA, ultrasound for FNAs and 131-I administration or clinical pathology for laboratory testing.

In many settings, the clinical endocrinologist can generate support only through direct face-to-face interaction with patients.

Because the patients typically referred to the endocrinologist present either a diagnostic challenge or complications caused by the interaction of multiple chronic conditions, the intensity of care required in the evaluation, diagnosis, initiation and coordination of therapy is substantial.

James V. Hennessey

The typical need for coordination of care of many endocrine conditions results in frequent patient interactions, which are required to achieve optimal outcomes but are not reimbursed if they occur between scheduled visits. This results in a substantial mismatch between the financial resources available to support ongoing patient care needs and the medical personnel who deliver that care.

Reforming financing

Recent proposals to reform health care financing and especially curtail the growth of health care spending include implementing reimbursement systems that do not depend solely on the volume of services provided. Rather, these proposed reforms focus on measures to reward preventive care, the management of chronic conditions, care coordination and enhanced health outcomes. From a clinical endocrinologist’s perspective, such an approach might result in an easing of the economic pressures that are a consequence of the current approach to reimbursement.

Recently, the American College of Physicians has made comprehensive recommendations for health care financing and delivery reform. Among the seven major components of this comprehensive plan, the institution of the patient-centered medical home has been put forward as the cornerstone of enhancing patient outcomes, saving resources and enabling medical practices to remain financially viable.

As outlined in this column, the proposal incorporates multiple elements, which accurately describe the type of care provided by clinical endocrinologists for patients with chronic diseases such as diabetes and those with complicated cases of thyroid, parathyroid and adrenal disease.

The College proposal specifically recommends that “The federal government provide dedicated funding to states that have requested federal support for their efforts to redesign their health care delivery programs to achieve measurable expansions of health insurance coverage and to redesign health care financing and delivery systems to emphasize prevention, care coordination, quality and use of health information technology through the Patient-Centered Medical Home.”

The patient-centered medical home positions the physician to offer services as a personal physician who leverages the key attributes of the assembled resources to coordinate and facilitate the care of patients and to be directly accountable to each patient. As personal physicians, the provider advocates for and provides guidance to patients and their families as they negotiate the complex health care system. The College believes that this arrangement provides better effectiveness, increased efficiency and more equitable care to individuals and populations while providing the potential of lowering the overall costs of care.

As might be expected, this modified practice arrangement, which simulates to some degree a concierge-like approach to service, would likely require more resources than those typically available in the usual medical office setting.

To address this issue, the College’s patient-centered medical home model includes a series of recommendations for reforming payment policies, including new models for paying physicians for coordinating care for patients with chronic diseases, increased payment for office visits and other evaluation and management services. In addition, the proposal includes a requirement for separate payment for telephone and e-mail consultations for nonurgent health issues, which are proposed to reduce the need for more costly face-to-face visits, and additional payments to physicians who use electronic health records to improve quality.

Finally, the College strongly believes that linking this degree of care coordination with appropriate support systems will result in overall quality improvement, enhanced communication and access, as well as improved, cost-effective outcomes.

In general, this proposal sounds very appealing to internists who provide care to patients with complex chronic conditions where frequent between-visit contact and coordination is common. The potential of enhancing support for quality care also is very attractive in the environment where evaluation- and management-coded reimbursements are limited. But, as is commonly said, the devil is in the details. Before the endocrine community can participate in the patient-centered medical home process we need to consider how this system is performing as it is implemented in currently ongoing pilot projects, and we must consider as yet unanswered questions concerning how the participation of subspecialists would occur.

Pilot programs

Pilot programs linking physicians and insurers have been implemented to evaluate the potential of paying more to coordinate complex care to focus on quality and realizing actual cost reductions. Interventions have included several approaches to implementing the patient-centered medical home concept.

One such demonstration took place at a small multispecialty practice and committed a disease management call center nurse to provide consistent and familiar phone contact to patients. In addition, a full-time LPN was put in charge of assuring that the call center nurse was continuously updated on the physician’s latest instructions. Among the measures targeted were outcomes of several chronic medical conditions including diabetes and preventative measures such as influenza vaccinations. Because this arrangement was linked to a pay-for-performance incentive and the outcomes were evaluated by actual chart audits rather than claims data, the results seem solid.

At the end of the first year, the physicians are said to have documented an increased number of foot ulcers in the diabetic patients and identified more cases of early stage peripheral vascular disease. The practice received an additional 20% reimbursement above that expected for caring for these patients by achieving the performance benchmarks.

In this process there was an increase in the primary physician, subspecialty physician and generic drug use costs experienced, but institutional costs to the insurer for hospitalization, rehabilitation and skilled nursing care decreased significantly. As a result of this experience, the insurer is expanding the pilot program to a dozen other groups.

Another pilot project established a registry to track data on diabetic patients by providing interest-free loans to a physician group to install an electronic health record system. To track the care of the diabetic patients, the group received a quarterly per member fee, which totaled about $36,000 for the 325 program participants insured by the company underwriting the program.

After initial start-up costs were absorbed and the electronic medical record enhanced office efficiency, the program was self-sustaining for all 800 patients with diabetes followed in the practice. In this project, the insurer’s medical director’s impression was that the savings being realized as a result of fewer hospitalizations outweighed the additional pharmacy costs. In this example, there is not a clear financial advantage to the practice, but quality of care and apparent improved outcomes likely resulted in a net patient benefit.

These private insurer projects and others illustrate and discuss the potential benefits of the patient-centered medical home but the majority of patients with (sometimes multiple) chronic medical conditions receive coverage from the Centers for Medicare and Medicaid. It is said that the average CMS patient sees seven different physicians every year and purchases 20 different prescriptions.

Eight health care organizations have been chosen to participate in three-year demonstration projects incorporating the patient-centered medical home concept to assess how physician-directed models of providing comprehensive care will succeed. The practical implementation rewards the participating physician with an enrollment fee and ongoing, per-patient quarterly payments. In these projects, the insurer provides community-based nursing support in the physician office and in the patient’s home as well as the installation of electronic patient registries. Reimbursement reforms include additional physician payments for enrolling patients in the model, achieving clinical goals said to be based on evidence-based guidelines and for completing so-called chronic care feedback forms that document the degree of care coordination that occurs in the management of these patients.

Through implementation of all these elements, it is likely that individual physicians will experience higher costs while establishing the chronic care model but would eventually gain enhanced efficiency and higher quality care. These results are expected when these pilot projects are finally completed and reported during the next year or so. The insurers, for their part, will of course continue to focus on the bottom line, but will likely realize that investing in preventative care and supporting physician practices through incentives may be the best way to save in the long run.

We have reviewed the basic proposal for enhanced primary care through the implementation of the patient-centered medical home. In the second part of this column, to be published in the February 25 issue of Endocrine Today, we will consider how this arrangement might apply to the clinical endocrinologist in practice. Stay tuned ...

James V. Hennessey, MD, is an Associate Professor of Medicine at Harvard Medical School in the Division of Endocrinology, Beth Israel Deaconess Medical Center, Boston.

For more information:

• Berenson RA, Hammons T, Gans DN, et al. A house is not a home: keeping patients at the center of practice redesign. Health Aff. 2008;27:1219-1230.
• Colwell J. Key ‘medical home’ model elements hit the market. ACP Internist. 2006;4:1-6.