What Care Enhancement Services justify enhanced payment ?

In my last post, we discussed the orientation and philosophy of the personal medical home, as advocated by the American Academy of Family Physicians (AAFP) and the American College of Physicians (ACP). A reasonable question to ask is, what exactly is being done by the doctor and staff that justifies enhanced payment to the physicians office? What are the services that do not fall into the usual payment for an office visit?

Recently, my medical group entered into a pioneering contract with a Medicare Advantage insurance company to hammer out these details as part of a new Medicare Advantage plan. Here is what we came up with:

Personal Medical Home Care Enhancement Services

• Maintain the patient's "personal medical home" electronic health care record, which includes an updated medication list, problem list, and records of all care provided and summaries of care received outside the family physician's office.

• Systematically remind members of covered preventive screening services.

• Apply the Wagner Chronic Care Model of pre-planned office visits to provide medical care for chronic conditions. This model includes the following:

1. A registry system for chronic conditions including but not limited to congestive heart failure and high-risk diabetes, that allows the medical team to identify patients with chronic conditions, assure that the needed care is delivered, and recall the patients for the regular follow-up care necessary for their condition.

2. Software for decision support, available in the room at the time of care. Family Care Network has invested in computerized software that provides evidence-based guidelines for care in the room for patient and health professionals to utilize at the time of services. This software also allows health professionals to link on the web to medical library services from the exam room.

3. The use of clear patient-friendly tools to enable patients to understand their chronic conditions and the actions necessary for them to achieve optimal health.

4. The use of clinical staff to support the patient in self-managing and telephone support, depending on the patient's needs.

• Provide regular quality reports (as agreed) for the insurance companies patients.

• Conduct an annual risk assessment for each member at which time the member's chronic medical problems are identified, reviewed and updated.

• Maintain the patient-doctor health care relationship between office visits by using telephone care and the Doc InTouch secure web messaging system when appropriate. This will enable more frequent interactions with the health care team to facilitate patient self-management.

These "deliverables" for the insurance company are value added work that is in addition to what is normally expected. Taken together, these measures provide a concrete framework that allows for much better patient management, and patient outcomes. If this approach was emulated nationally, it would go a long way to improve our national health care scorecard, and at the same time dramatically improve the financial health of family physician offices.