Subspecialists Willing, Even Eager to Work With FPs

PCMH Model Should Improve Communication, Coordination

February 17, 2009 03:50 pm David Mitchell

Perhaps one of the least recognized benefits of the patient-centered medical home, or PCMH, is the opportunity it offers to improve the way primary care physicians and subspecialists work together. Optimizing these collaborations could lead to systemwide cost savings that have the potential to directly benefit all physicians -- those in primary care and their subspecialty colleagues.

The trick to getting it right, two of those subspecialists tell AAFP News Now, involves finding common ground, while at the same time, playing to each others' strengths.

"The role of the orthopedists in the (PCMH) model will still be to provide specialized evaluation and treatment for problems, conditions and injuries of the musculoskeletal system," says Douglas Dirschl, M.D., chair of the department orthopedics at the University of North Carolina at Chapel Hill.

"What will be different," he says, "is that there will be better communication and coordination between the orthopedist and the primary care physician regarding musculoskeletal diagnoses, treatment plans and goals."

Dirschl, who also chairs the American Orthopaedic Association's Critical Issues Committee, says that in the PCMH model, the primary care doctor will be better able to understand a patient's musculoskeletal issues and communicate with the patient in a way consistent with the orthopedist. Meanwhile, the orthopedist will have a better understanding of the patient's overall wellness and health goals.

"By working together, the primary care physician and the orthopedist can provide better overall care for a large number of conditions," he says.

One example, according to Dirschl, is a fragility fracture caused by osteoporosis. The fracture may be treated by the orthopedist, but the underlying osteoporosis would be treated by the primary care physician.

"National data indicate that only a small percentage of patients with fragility fractures receive evaluation and treatment for potential osteoporosis," he says. "By working better together, the orthopedist and the primary care physician can close this treatment gap."

Collaborating on the Patient Care Process

Although use of electronic health record, or EHR, systems to share patient information is a critical component of the PCMH, Jack Lewin, M.D., CEO of the American College of Cardiology, says cooperation and coordination need to go beyond sharing electronic records.

Such systems should include Web-based tools for primary care doctors, "who can't possibly keep track of the evolving science in all specialties," says Lewin.

"We have to flip how the delivery system has worked -- or not worked -- to create a system that is patient-centered," he says. "What's best for the patient? That's first.

"Secondly, how do we make sure we provide consistent, scientific, evidence-based care? If your internist believes, 'This is the way I want to treat your hypertension or diabetes,' but your endocrinologist or your cardiologist has a different strategy, that's not going to work well. There has to be some agreement between those who are gathered around the patient about what the care process will be."

Primary care and subspecialist physicians need to collaborate on such process elements as clinical decision support, treatment guidelines, performance measures and criteria for appropriate use of technology, Lewin adds.

The ideal scenario would be a multispecialty practice where a patient can see his or her primary care physician and other specialists in one location, with the doctors working together, says Lewin.

"That isn't a practical reality in rural America or smaller communities, but where it can happen, it should happen," he says. "Where it can't happen because it just isn't feasible to have a primary (care physician) and an array of (subspecialists) working in one facility, there ought to be a virtual integration between (primary care physicians) and (sub)specialists who are able to better coordinate and communicate about the care of a patient."

Although primary care physicians are expected to manage the care of most patients in the PCMH model, Lewin says subspecialists could be the medical home in some instances.

For example, in cases of complicated heart failure, heart transplants or an unstable arrhythmia, a cardiologist's practice might serve as a medical home, he notes.

"We think there will be other specialties that will do this," he says. "This won't be a typical situation for a (sub)specialty practice or cardiology, but one that needs to be considered in the process as what will be best for the patient in certain circumstances."

Realizing Systemwide Benefits

The past year has seen demonstrable progress in bringing subspecialists into the PCMH fold.

During the 2008 interim meeting of the AMA House of Delegates in Orlando, Fla., AMA delegates adopted the Joint Principles of the Patient-Centered Medical Home developed by the AAFP, the American Academy of Pediatrics, the American College of Physicians and the American Osteopathic Association.

According to those principles, the PCMH is designed to improve quality of care, enhance access to care, coordinate care to enhance the patient-physician relationship, and establish a payment structure that recognizes the value of and pays physicians appropriately for coordinated services and care management.

"It's not a matter of, 'Let's cut one physician to give to another,' but rather let's increase the level of compensation for primary care at a far more rapid rate to make primary care practice more attractive for those who are in training," says Lewin, whose background is in primary care.

Between 20 percent and 30 percent of Medicare patients who leave hospitals after being diagnosed with heart failure return within 30 days, says Lewin.

"The cost of that is in the tens of billions of dollars," he notes. "We could provide a 10 percent payment increase for every doctor in America if we just reduced the number of unnecessary readmissions for heart failure by 50 percent in this country. It would benefit patients, and it would benefit doctors. We can't solve the financing problems and challenges in medicine unless we do these things together."