As health care reform moves forward, many subspecialist physicians are concerned that they lack a clearly defined role in coordination of care to be provided through the patient-centered medical home.
“We're a little bit frustrated about where we fit in,” said Dr. Karen Kolba, a rheumatologist in solo practice in Santa Maria, Calif., and chair of the American College of Rheumatology's Committee on Rheumatologic Care.
The ACR is one of a handful of medical specialty societies that has not signed on to the concept of the patient-centered medical home. It's not that the college doesn't support increased access for patients or coordinated care; rather, she said, rheumatologists feel that they have been excluded from the model.
In 2007, the American College of Physicians—along with the American Academy of Family Physicians, the American Academy of Pediatrics, and the American Osteopathic Association—issued a paper outlining principles for providing comprehensive primary care through the patient-centered medical home.
In the medical home model, each patient has a personal physician who directs a practice-based care team and is responsible for providing all of the patient's health care needs or coordinating that care with other providers. The model also emphasizes enhanced access for patients, evidence-based medicine and clinical decision support, and additional payment for the personal physician for providing care coordination and improving quality.
A voluntary recognition program created by the National Committee for Quality Assurance (NCQA) aims to support the development of medical homes. Physicians who meet the program's standards can qualify for additional payment from certain health plans. The NCQA standards measure a practice on elements such as access and communication, patient tracking and registry functions, care management, referral tracking, and electronic prescribing.
Although the medical home model doesn't specify that only a primary care physician can qualify, the criteria make it nearly impossible for a specialty practice to serve as a medical home, Dr. Kolba said. For example, rheumatologists frequently are the main point of medical contact for patients with chronic rheumatologic diseases, and they provide a significant amount of coordination of care, she said. However, few perform or coordinate nonrheumatologic care such as regular mammography, and that's a sticking point in being able to qualify as a personal physician under the medical home model, she said.
Dr. Kolba said she supports increasing payment for primary care, but not at the expense of other physicians. Primary care physicians ought to be entitled to additional pay for the work they do, without creating a new system to justify the increases, she added.
The American College of Physicians, whose membership includes both subspecialists and primary care physicians, has given a lot of thought to how specialists could and should function in the medical home model. D
Dr. Michael S. Barr, the ACP's vice president for practice advocacy and improvement, said the medical home model is set up so that some subspecialists could qualify as a personal physician. For example, a nephrologist who cares for patients with end-stage renal disease would be a good candidate. Whether that physician would want to go through the recognition process is a separate issue, he said.
“There is definitely a place in the restructuring of the way we deliver health care for general internists, family physicians, pediatricians, and all of our subspecialty colleagues,” Dr. Barr said. “This is about providing better care for people and populations.”
Down the line, subspecialists are also likely to play a role as part of a broader “medical home neighborhood,” he said. That concept is still being defined, but the idea is to improve communication among physicians on patient hand-offs and find a way to reimburse physicians for some of the interactions that currently go unrecognized, Dr. Barr said.
For example, a conversation between an orthopedic surgeon and an internist about managing a patient's back pain could save the health care system a significant amount of money on unnecessary procedures. Right now these conversations are done on a collegial basis, but in the future, the medical home neighborhood model might allow payment to both physicians for this type of early collaboration, he said.
The hope is that the money to fund additional payments for specialists and primary care physicians could come from overall health system savings, such as reductions in unnecessary emergency department visits and hospital admissions and readmissions, Dr. Barr added.
Leaders of the American Academy of Family Physicians also acknowledge the role of specialists in the patient-centered medical home model. The medical home was purposefully defined to include a “personal physician”—not a primary care physician, said Dr. Terry McGeeney, the president and CEO of TransforMED, a subsidiary of the AAFP that helps primary care practices transition to the medical home model. A
Although most practices using the medical home model will be led by primary care physicians, not all will be. The personal physician could be an infectious disease specialist, a neurologist, or an oncologist, he said.
But the key, Dr. McGeeney said, is that the physician must provide a medical home for the whole patient, and not focus on a certain disease or organ system. That means that a neurologist, for example, must keep track not only of the neurologic care, but also the patient's cholesterol levels and mammography results. They don't have to perform these services themselves, but they have to coordinate and track them, he said. In the medical home, the personal physician is the “quarterback” for the patient's care and there's no “free pass” on those responsibilities for specialists, he said.
Specialists who do want to provide a medical home may even have an advantage, said Dr. McGeeney, who pointed out that specialty practices tend to have more resources to invest in practice transformation. That said, specialists often have not been trained to provide the types and level of care required of medical homes.
Where specialists may fit in more easily, Dr. McGeeney said, is in the medical home neighborhood, which includes all of the physicians caring for a patient, as well as the emergency department, the hospital, and the pharmacy.
TransforMED is encouraging medical home practices to have letters of agreement with specialists regarding care coordination. As part of the agreement, the primary care physician promises to send all the patient's information to the specialist and to communicate about tests and results. These agreements aren't legally binding on either party, but they force everyone to have a conversation about coordination of care, he said.
Still, some specialists remain skeptical about their role in the medical home and the medical home neighborhood. Dr. Alfred Bove, past president of the American College of Cardiology and emeritus professor of medicine at Temple University, Philadelphia, said cardiologists frequently act as a medical home for heart failure and transplantation patients, for example. For years, many cardiologists have worked in multidisciplinary care teams, used electronic health records, and provided immunizations and screening, he said. <
“We have all the ingredients needed to be a patient-centered medical home in an area of chronic disease that probably is better done by cardiologists that have a lot of experience in managing very sick heart failure patients than in a primary care practice where there's a broad spectrum of different kinds of patients,” Dr. Bove said.
The ACC has been advocating for specialty-based patient-centered medical homes in specific areas where the cardiologist's expertise is unique and they would be willing to assume responsibility for preventive care.
Another issue is what to do about specialty practices that act as a medical home for only a portion of their patients. A recent study looked at single-specialty practices in cardiology, endocrinology, and pulmonology to find out to what extent those specialty practices function as medical homes.
The researchers found that a large percentage of the practices provided both primary care and specialty care, but generally for a subset of patients. For example, 81% of the 373 practices surveyed served as primary care physicians for 10% or fewer of their patients. Only 2.7% of the practices act as primary care physicians for more than 50% of their patients (N. Engl. J. Med. 2010;362:1555–8).
Dr. Bove said he suspects that cardiologists are acting as medical homes for a larger number of patients than cited in that study. But either way, he thinks a system could be developed that would allow cardiologists who are willing to invest the time in qualifying as medical homes to be recognized and paid for providing such care, even if another portion of their practice is devoted primarily to procedural services.
For its part, the ACC has established a Patient Centered Care Committee that is working on cardiology models for the patient-centered medical home. The committee is setting up protocols so that cardiologists who are interested can apply to medical home pilots being set up under the new health care reform law.
Endocrinologists face similar challenges in qualifying as the medical home. About 50%–60% of the average endocrinologist's time is devoted to care for diabetes patients, and the remaining time is spent consulting on other conditions, said Dr. R. Mack Harrell, an endocrinologist in Fort Lauderdale, Fla., and a member of the board of directors of the American Association of Clinical Endocrinologists.
“It's hard to see how you could completely give up your consulting role so you could fit into a medical home–type model for half your practice,” Dr. Harrell said.
Seeking to ensure that endocrinologists, and all physicians, are paid for the administrative burdens that take up so much time, the AACE is working to generate a new CPT code for preauthorizations.
Dr. Harrell said the key will be to ensure that primary care physicians and specialists find better ways to communicate with one another. But communication will be an ongoing challenge, especially since Medicare is no longer paying specialists more to perform consultations. “None of the codes … are specifically constructed to pay for communication between physicians,” he said.
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