Patient-Centered Medical Home takes team approach to care

Spending less of your time trying to see your primary-care physician could be a sign of good health — or it could be part of what appears to be a paradigm shift in health care known as the Patient-Centered Medical Home, or PCMH, model.

Proponents of the new model — which stresses a team approach to providing health care rather than the single gateway that has long been the role of the primary-care physician — hope it also will become synonymous with better health. The incoming results of the new model, which is rapidly gathering steam with both physicians and insurance companies, have been remarkably positive this far.

“That traditional setting we had is 100 years old, … (from) when doctors were basically a cottage industry,” said Dr. Austin Bailey of Loveland, a family physician and medical director for primary care at the University of Colorado Health Care partners. “With the complexity of conditions now and the complexity of the health-care system, one individual provider cannot do all the work.”

Consider the average primary-care physician who needs a client base of about 2,000 patients for a healthy practice. In turn, that would mandate an average of 17 hours a day, when taking in a full schedule of patients and handling the paperwork, along with analyzing lab results and handling referrals to specialists.

This has led to a high burnout rate among primary-care physicians and a decided lack of those doctors in the workplace, he said. But in changing from a production-based to a value-based model, Bailey said both doctors and patients are reporting a higher degree of satisfaction.

In 1980, Bailey said, the director of his residency program gave him the following breakdown in what would bring his patients in for a visits: “Forty percent are purely behavior origin, another 40 percent may be physical but there will be a behavioral overlay. Only about 20 percent will have pure physical complaints, such as an infectious disease or an accident.

“I didn’t really believe it at the time, but the numbers are actually probably worse,” said Bailey, who has spent almost his entire career as a family doctor. “What has now happened over the last 20 years, is we’ve had an epidemic of chronic conditions: high blood pressure, diabetes, obesity …”

In the value-based PCMH model, however, these chronic conditions could be overseen by a wide variety of team members, who would include behavioral therapists, psychiatrists, physician specialists, registered nurses, physician assistants and even social workers, who could help patients with a variety of issues, including how to pay for treatment.

Dr. Jason Cannell
Cannell
Dr. Kit K. Brekhus
Brekhus
Dr. Austin Bailey
Bailey

Bailey compared the new role of the primary-care physician to that of Peyton Manning in his last season with the Denver Broncos, rather than the first 17 as the play-making football star: “He’s still the quarterback, but he’s managing the game more, rather than making all the plays,” said the UC medical director.

No one is saying the initial expense is incidental. In Colorado, the cost for a single primary-care physician to meet the staffing and care-coordination requirements cost more than $9,000 a month, according to a study published in the “Annals of Family Medicine.”

However, a multi-payer study of a pilot program for PCMH models in Colorado saw a 15 percent drop in emergency department visits. Additionally, there was an 18 percent dip in inpatient admissions, leading some analysts to suggest the return on investment was as much as 4 to 1.

UCHealth’s network of primary-care facilities is only five years old, but about 80 percent of the facilities now are certified or close to certification by the National Committee on Quality Assurance. Physician clinics with Boulder Community Health were early adopters of the value-based model, and most providers have top (Level 3) certification, although recertification is a continual process.

“The major draw for us was the impact of the quality of care,” said Dr. Jason Cannell, a physician at Boulder Creek Family Medicine that affiliates with BCH. “There was some underlying tome that this was the direction that health care was going, but it was really to serve the community.”

Still, there have been advancements in reducing medical costs.

“In particular, there has been an emphasis on emergency-department readmission” indicating the causal element in the initial emergency visit had not been fully addressed, said Cannell, who was well-versed in similar value-based models while serving in the military. “We’re really moved the needle there.”

However, Cannell said that for the individual practitioner, there is a tremendous advantage in addressing the gaps in care that any one of 2,000 clients may be falling through, and a great deal of that is the underlying technology that allows team members to share information.

“It becomes very easy to see the percentage of people who are receiving influenza vaccines, or which diabetics are getting to controlled conditions,” he said. “That’s where we are really seeing an impact.

“As a physician and provider, it increases the time we can spend face to face with a patient,” he said. But for the insurance companies — or payers, in the terminology of the field — there appear to be tremendous advantages in the improvement of the continuity of care and the reduction of duplicative services.

“The dietitian I use — I know them and we speak on a daily basis,” as well as sharing the same medical records, Cannell said. “The insurance companies understand the value gained in that relationship, as well as the improved continuity of care. This model helps to close that gap.”

But a real bottom-line savings are obviously realized in that services such as lab work or x-rays are all available to the team, and so are less often duplicated, as they might be when a patient is sent to a specialist outside of the network.”

Adoption of the model is not instantaneous, of course, as the production-based model that precedes it saw much of the billing belong to the primary-care physician. But experts said older doctors and even “star” specialists — such as an orthopedist who treats big-name athletes — are moving into the team approach.

“They see the value as well,” said Dr. Kit K. Brekhus, the executive physician director for Colorado Health Neighborhoods, a network of independent providers associated with Centura Health. “That starting orthopedist doesn’t want to be overwhelmed by a bunch of knee sprains, he wants to be rewarded with the high-quality surgeries he does best.”

CHN, a physician-led network of more than 4,000 employed and independent affiliated providers partnering with Centura Health, was formed to help develop the backbone necessary to create PCMH models.

“Every practice in our network is in some stage of this journey” toward PCMH certification, Brekhus said.  His own story illustrates what makes it attractive.

“I owned my own practice in family medicine and emergency care — with 26 employees and five docs,” he said. “One person was not enough to make it work. I was incredibly busy trying to keep up with the hassle of running two clinics, but I liked the autonomy.”

One area in which it becomes very difficult to keep pace is technology, Brekhus said. Talking with other independent providers, he found that was a common theme.

Spending less of your time trying to see your primary-care physician could be a sign of good health — or it could be part of what appears to be a paradigm shift in health care known as the Patient-Centered Medical Home, or PCMH, model.

Proponents of the new model — which stresses a team approach to providing health care rather than the single gateway that has long been the role of the primary-care physician — hope it also will become synonymous with better health. The incoming results of the new model, which is rapidly gathering steam with both physicians and insurance companies, have been remarkably positive this far.

“That traditional setting we had is 100 years old, … (from) when doctors were basically a cottage industry,” said Dr. Austin Bailey of Loveland, a family physician and medical director for primary care at the University of Colorado Health Care partners. “With the complexity of conditions now and the complexity of the health-care system, one individual provider cannot do all the work.”

Consider the average primary-care physician who needs a client base of about 2,000 patients for a healthy practice. In turn, that would mandate an average of 17 hours a day, when taking in a full schedule of patients and handling the paperwork, along with analyzing lab results and handling referrals to specialists.

This has led to a high burnout rate among primary-care physicians and

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