For some primary care physicians, the idea of transforming a practice into a medical home sounds like a major risk.
Yet practices that have made the change in states such as Rhode Island have reported smooth transitions, thanks in part to financial and technical support from public and private entities. By hiring a care manager and training existing staff to take on additional care tasks, the model can succeed, these physicians say.
Family physician Gregory Steinmetz, M.D., left, Julie Rousseau, F.N.P.C., and Martin Kerzer, D.O., review patient information at the Associates in Primary Care Medicine office in Warwick, R.I. The three are part of the practice's medical home team.
Nearly half of all states have made patient-centered medical homes a priority, thanks in large part to state funding and cooperation among private insurers. As of June of last year, 18 states were participating in multipayer medical home initiatives, and five others were planning similar efforts, according to an October 2014 report(www.nashp.org) by the National Academy for State Health Policy.
In Rhode Island, where the state mandates that insurance companies devote 10 percent of spending to primary care, the Rhode Island Chronic Care Sustainability Initiative(www.pcmhri.org) (CSI-RI) is one model for making a transition from a traditional fee-for-service practice to the patient-centered medical home (PCMH). The initiative began in 2008 as a pilot project involving just five practice sites and is slated to become a nonprofit with a new name, the Care Transformation Collaborative of Rhode Island, in June.
About 300 primary care physicians participate in the initiative, which now includes 73 sites and covers an estimated 320,000 patients. The goal is to reach 500,000 patients in the next three years.
- One family physician in Rhode Island explains how incentives paid through a state-funded initiative and private insurers allowed him to transform his practice into a medical home.
- Per-patient monthly payments made under the program range from $6.50 to $8.75 per patient based on quality performance.
- Participants in the program are expected to use the monthly payments to cover overhead during the transition and to build a sustainable infrastructure, not as a revenue supplement.
"You need a solid and deep primary care foundation," said CSI-RI Co-director Debra Hurwitz, M.B.A., R.N. "That is what PCMHs are about versus having (them) being built on hospitals and specialists."
Monthly payments for practices participating in the initiative during the past two years ranged from $6.50 to $8.75 per patient based on quality performance. Practices submit performance data quarterly, and if they don't meet performance targets, they don't get bonuses.
Overall, fee-for-service still constitutes more than 90 percent of practice revenue, Hurwitz said. She acknowledged that fee-for-service is unlikely to drop to zero in any care delivery model but said it could be reduced substantially by combining a value-based payment with an infrastructure payment and other incentive payments.
The monthly payment provides an effective framework for building a more advanced primary care practice, Hurwitz noted. CSI-RI practices are required to use part of the monthly payment to hire an on-site nurse care manger. No requirements are placed on how the rest of money is to be used.
Physicians can join the initiative during any one of four phases: startup, transition, performance year one and performance year two. They have two years to obtain level 3 PCMH recognition from the National Committee for Quality Assurance (NCQA), and they can take six months more if they fail to qualify initially. Hurwitz said no office has failed to date.
Gregory Steinmetz, M.D., a family physician in Warwick, R.I., said his practice received substantial support from TransforMed and funding from Blue Cross when it became a medical home in 2008. Now a level 3 PCMH, his practice receives a $6 payment per patient each month. The practice, which has a panel of about 3,000 patients, recently joined an accountable care organization (ACO).
"For us, with incentives in place, it worked out," he said. "We have enough to meet our needs and the resources to pay a nurse."
The initial transition to a medical home was the toughest part, said Steinmetz. However, practices do not need to pass every hurdle on their own. A practice transformation committee meets monthly, and CSI-RI representatives work with individual practices to help them through the transition.
In addition to seeing patients in his Warwick, R.I., practice, family physician Gregory Steinmetz, M.D., also precepts medical students.
"When you look at the list of things that need to be done, you think, 'Oh, my gosh, how are we going to accomplish all of this and achieve (NCQA) recognition?'" Steinmetz said. "It seemed daunting at first."
Hiring a nurse was the major change in the office. In Steinmetz's case, Blue Cross gave the practice a bonus for achieving NCQA recognition, which funded the cost of the nurse care manager. Although the nurse serves as the care manager, the physician continues to make major decisions.
As for other benefits the practice has realized since transitioning to the medical home model, "It's kind of a gateway to be eligible for shared savings," Steinmetz said. "It works out financially if the practice commits to it and wants to make it a success."
Steinmetz said the funds received for becoming a PCMH have also helped offset the cost of increased overhead. As part of participating in the CSI-RI, the practice expanded its hours, including staying open on Thursday nights and Saturdays. In most cases, patients can be seen within a day of calling the office.
Benefits for patients also include more direct communication when they are not in the physician's office. For example, every patient who goes to the ER receives a follow-up phone call and is encouraged to visit the physician's office. Patients who are admitted to the hospital receive a phone call asking them to schedule an office visit.
A nurse handles a larger portion of patient education tasks, such as ensuring patients can use a glucometer, giving instructions on medications, and offering guidance on diet and exercise. The nurse also identifies potential barriers to receiving care, such as employment obligations or transportation limitations.
Medical assistants also are more involved with planning before patient visits. The nurse care manager and medical assistant reconcile patient medications by phone before a patient's office visit and again during the visit.
Although some have expressed concern that staff and physicians would spend substantially more time each day with patients, Steinmetz has found that fear unfounded as long as patient care responsibilities are divided broadly among the entire care team.
"Physicians don't have any more time, so it's critical to delegate tasks and hire very good people who are trustworthy," Steinmetz said. "You can give them a task, but you have to manage them. If you can do that successfully, it doesn't translate into longer days."
In one example, medical assistants were trained to conduct a diabetes monofilament foot exam, which Steinmetz said revealed a previously unrecognized shortfall.
"We thought we were doing this on a regular basis, but we really weren't," he explained. "Once we got a medical assistant involved, exam rates went way up."
Thomas Bledsoe, M.D., tapped to serve as president of the Care Transformation Collaborative of Rhode Island when it formally launches this summer, practices at one of the original five CSI-RI sites. He recalled the early discussions about the initiative among physicians and insurance companies.
"We were asking, 'What's wrong with the way we deliver and pay for primary care?'" he said. "Everybody was pointing fingers at each other."
As those discussions went on, Bledsoe explained, the groups came to realize that one way to improve care is by changing the payment structure to allow more flexibility in patient care so a physician can spend more time on pre-visit planning and more time consulting with a patient if needed. For example, most office visits are scheduled in 15-minute intervals. For many chronic care patients, however, that simply isn't enough. But expecting a physician to singlehandedly manage a daily patient load of 30-minute visits isn't realistic, either.
In such cases, the practice can bill the insurance company for 15 minutes and CSI-RI for an additional 15 minutes, and other practice staff can help spread out the actual workload. Bledsoe said protocols define when the extended time would be appropriate to guard against overbilling.
Like Steinmetz, Bledsoe pointed to other specific changes that can be made at the practice level, such as ensuring that all patients in the practice who are discharged from the hospital are seen in the physician's office within 48 hours. To facilitate this, the practice can arrange to receive regular reports from area hospitals and ERs to know when patients visit, Bledsoe said.
Ideally, practices are also able to review a high-risk patient list from Medicare and private plans so physicians can manage those individuals who are likely to require more care at a higher cost. Each practice maintains a list of highly complex patients, and the nurse care manager tracks their progress.
"In the past someone might ask, 'How are you doing with diabetes patients?' and we'd say, 'Oh, pretty good.' Now we have proof that patients are doing well compared with the past," Bledsoe said.
Bledsoe said that although practices involved in CSI-RI noted a 7.2 percent reduction in ER visits, hospital visits did not decline. Realistically, however, reducing that rate could take years, he noted.
Finally, the collaborative is not meant to be a permanent home for participating physicians, according to Bledsoe. The monthly payment is intended to offset infrastructure costs, not redirect payments to physicians for patient care, he said, and after four years, practices that demonstrate success are expected to move into an ACO or a shared savings plan.
"We recognize that primary care is wildly underfunded and not sustainable in its current form," Bledose said. "There are so many ways that we can improve that. We're about 5 (percent) to 10 percent of the way there."
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