Part 2: the patient-centered medical home

Where does the internist, endocrinologist fit in?

In the first half of this discussion, published in the January 25 issue of Endocrine Today, we reviewed the basic proposal for enhanced primary care through the implementation of the patient-centered medical home. In this part of the article, we will consider how this arrangement might apply to the clinical endocrinologist in practice.

At this point it may still be unclear to you what actually constitutes this “Advanced Medical Home.” Many of the key elements sound very familiar to the practicing endocrinologist while at the same time being different from many of our current practice realities. This model assumes the physician in the patient-centered medical home (PCMH) is a patient’s primary care physician who partners with patients to ensure that all health care is effectively managed.

Patient self-management

James V. Hennessey, MD

The expectation is that avoidable complications would be prevented by enhanced patient self-management. With the exception of the primary care designation, this certainly sounds like a description of the endocrinologist’s relationship with many patients, especially those with diabetes.

Secondly, physicians and their teams, not insurer-employed case managers, would coordinate the chronic care of the patient. Again, this does sound very familiar.

Further, physicians would identify key quality indicators and demonstrate continuous improvement of chosen clinical outcomes. This would be accomplished through the use of electronic health records to store clinical data and test results as well as to implement clinical decisions based on evidence-based guidelines.

Additionally, physicians would provide, and be reimbursed for, non-urgent medical advice and follow-up care such as blood sugar result review and medication dosage adjustments through e-mail and telephone consultations. The physician directing the PCMH would team up with consultants and other health care professionals to provide a full spectrum of patient-centered services.

The American College of Physicians’ view of participation of internists in the PCMH includes medical subspecialists either as the primary care physician, a role that many of us likely play for a substantial proportion of the patients with diabetes or as the partner of the primary physician team providing comprehensive coordinated care. This difference of roles poses interesting questions, which are being discussed to better define how, if at all, the clinical endocrinologist will be able to participate in the advanced medical home process.

Endocrinologists should be positioned to benefit from the additional resources to be available in the PCMH for the services provided to their patients with complex chronic endocrine disease.

Enrolling as the PCP

The most direct approach for the internist-endocrinologist to benefit from the PCMH is to enroll as the PCP for those patients with qualifying chronic medical conditions. In many practices this arrangement is already de facto in place so many will find it natural to continue in this role. Of course, such an arrangement will likely distribute these patients between PCP and endocrinology practices by their degree of complexity of disease.

Those with new onset diabetes, who are otherwise healthy, would likely remain with the original PCP qualifying these practices for the additional practice support at a disease stage where the occurrence of minimal complications requires only straightforward care. In this case, the additional resources of the PCMH would probably more than cover the additional costs of providing the care.

Referral to the endocrinologist would likely be deferred until complications develop when the intensity of care likely outstrips the additional support available through the PCMH. At this point in time, it is unclear if the consultant endocrinologist would be restricted to a traditional fee for service arrangement with execution of the proposed care plan by the PCP’s team or if the endocrinologist would be expected to provide a parallel system of patient education, evaluation, care coordination and continuous follow up in line with current models.

Providing comprehensive care

If there can be only one physician designated as the PCP, it is likely that the consultant endocrinologist would provide comprehensive care if the responsibility were transferred into the endocrine PCMH. Otherwise it is unclear, and I would guess unlikely, that the additional PCMH support for comprehensive care would be feasible for both the PCP and the endocrinologist. This could result in a disincentive for referral or placement of limitations on the consultative interaction.

It is feasible that consultation would be intended only for care plan development (to minimize specialist visits) and there could be a requirement that the patient return to the original PCMH for care implementation and continuity. Requests by the patient or coordinating physician for advice from the endocrinologist between fee-for-service visits would likely continue to be unsupported.

If the care of the more complicated patients with diabetes were eventually transferred to the endocrine PCMH, it is likely that the extent of additional financial support would be the same as that offered to the PCP office providing PCMH services. Presumably the amount of care coordination, education and between visit care required of these most complex patients would exceed that budgeted in the additional support.

As actuaries are likely quite able to anticipate the dollar amounts necessary to cover this additional work (currently being absorbed by dedicated endocrine practices), it is likely that the additional support will not be excessive. It would seem that the endocrinologist might be at a financial disadvantage, especially if primarily providing care to the most complex and labor-intensive patients. A fair balance of straightforward and complex patients with the same qualifying diagnosis would seem a more reasonable situation if the extent of additional support were not prorated by the severity of disease and adjusted appropriately.

Focus of the patient’s care in the PCMH would appropriately direct all between visit questions to the primary care office for review and PCP triage. This would likely have a positive effect on patient care. I would anticipate far fewer calls for issues that the patient perceives to be related to the condition being followed by the subspecialist.

In my experience I receive such calls, as my practice may appear to be more accessible than the PCP offices that many of my patients visit. In any case, I redirect most such inquiries to the PCP after I have listened to the story, as the problem is usually outside the scope of subspecialty practice.

The endocrinologist accepting primary care responsibility to qualify for PCMH support, on the other hand, will need to directly address these general medical issue calls requiring urgent visits for primary evaluation of a multitude of complaints. In addition the endocrine PCMH director will experience an increase in the volume of referral and coordination calls for other specialists to address the general medical problems encountered in order to maintain the integrity of the comprehensive management of their panel.

Intermediate model

An intermediate model would have the patient seek all care through the primary care office; the PCP-directed PCMH practice would assess each complaint.

As perceived appropriate for the circumstance, the PCP would then either address the issue directly or personally seek subspecialty consultation to provide care to the patient. In this circumstance, the subspecialist’s uncompensated and by definition limited advice would be sought for patients that the subspecialist had previously seen in consultation (minimally acceptable) or would never see (curbside consultation), and the PCP would provide ongoing care of the chronic condition.

Obviously this scenario would sound outrageous and potentially dangerous for the care of the complicated patient with diabetes and could become an issue in some pituitary, adrenal and thyroid cases if this approach seemed appropriate to the physician directing the PCMH.

So how should we in endocrinology feel about endorsing the PCMH?

On the one hand, this model is designed to recognize the cognitive work provided by the non-procedural specialist in medicine. The additional support for coordination of care, between visit communication, management and education would be welcome and is a step in the right direction to make the fiscal survival of the endocrinologist possible.

Additionally, enhanced financial security might increase the perceived value of the endocrine specialist in the future and make it possible to attract the next generation of physicians into our specialty, assuring adequate numbers to meet the anticipated endocrine workforce needs.

It seems to me that many unanswered questions remain to be addressed and that more work is necessary to better define our place in this system before we as a subspecialty are ready to sign on to the PCMH. It will be necessary for the endocrinologist to have access to the support available through this model while being allowed to maintain the essence of our special calling.

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, Mass.

This is part 2 of a two-part series on the patient-centered medical home. Read part 1 in the January 25 issue of Endocrine Today.

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.