Monday, February 19, 2007

Joint Principles of the Patient-Centered Medical Home, agreed upon by the AAFP and the ACP

American Academy of Family Physicians

American College of Physicians

Joint Principles of the Patient-Centered Medical Home

July 2006


The American Academy of Family Physicians and the American College of Physicians have developed proposals for improving care of patients through a patient-centered practice model called the “medical home” (AAFP, 2004) or “advanced medical home” (ACP, 2006). Similarly the American Academy of Pediatrics has proposed a medical home for children and adolescents with special needs.

AAFP and ACP offer these joint principles that describe the elements of the patient-centered, physician-guided medical home.


Personal physician - each patient has an ongoing relationship with a personal physician trained to provide first contact, continuous and comprehensive care.

Physician directed medical practice – the personal physician leads a team of individuals at the practice level who collectively take responsibility for the ongoing care of patients.

Whole person orientation – the personal physician is responsible for providing for all the patient’s health care needs or taking responsibility for appropriately arranging care with other qualified professionals. This includes care for all stages of life; acute care; chronic care; preventive services; end of life care.

Care is coordinated and/or integrated across all domains of the health care system (hospitals, home health agencies, nursing homes, consultants and other components of the complex health care system), facilitated by registries, information technology, health information exchange and other means to assure that patients get the indicated care when and where they need and want it.

Quality and safety are hallmarks of the medical home:

Evidence-based medicine and clinical decision-support tools guide decision making

Physicians in the practice accept accountability for continuous quality improvement through voluntary engagement in performance measurement and improvement.

Patients actively participate in decision-making and feedback is sought to ensure patients’ expectations are being met

Information technology is utilized appropriately to support optimal patient care, performance measurement, patient education, and enhanced communication

· Practices go through a voluntary recognition process by an appropriate non-governmental entity to demonstrate that they have the capabilities to provide patient centered services consistent with the medical home model.

Enhanced access to care through systems such as open scheduling, expanded hours and new options for communication between patients, their personal physician, and office staff.

Payment appropriately recognizes the added value provided to patients who have a patient-centered medical home. The payment structure should be based on the following framework:

· It should reflect the value of physician and non-physician staff work that falls outside of the face-to-face visit associated with patient-centered care management.

· It should pay for services associated with coordination of care both within a given practice and between consultants, ancillary providers, and community resources.

· It should support adoption and use of health information technology for quality improvement;

· It should support provision of enhanced communication access such as secure e-mail and telephone consultation;

· It should recognize the value of physician work associated with remote monitoring of clinical data using technology.

· It should allow for separate fee-for-service payments for face-to-face visits. (Payments for care management services that fall outside of the face-to-face visit, as described above, should not result in a reduction in the payments for face-to-face visits).

· It should recognize case mix differences in the patient population being treated within the practice.

· It should allow physicians to share in savings from reduced hospitalizations associated with physician-guided care management in the office setting.

· It should allow for additional payments for achieving measurable and continuous quality improvements.

Saturday, February 3, 2007

Why Doesn't My Doctor's Office Take My New Insurance Plan?

Many people who get medical insurance through their employer have had the experience of the plan being changed by their employer from year to year. Usually the employer does this to save money on the premiums that they pay on behalf of the employee, and any other considerations are of a very secondary importance. This can be frustrating to employees, however, who may find that their personal physician either does not accept the new insurance, or is not a "preferred provider", which means that they will have to pay more for their care. Why don't doctors take every insurance? Here is a recent story that I am familiar with here in the Northwest.

A prominent employer was recently purchased by a new parent company, which made the decision to change the employee medical plan as part of cost savings measures. This medical plan they chose was not very active in the area, and so the plan gave the employer a very inexpensive price to try and "buy their business" and get a foothold in the community. Trouble was, very few doctors in the community had signed up with that plan. The local doctors were not consulted as to why they did not participate, and the employees of the company were not involved in the decision. It probably never even occurred to the company officials that their action might affect others in the community. Either that, or they did not care.

Suddenly, doctors were confronted with hundreds of their long time clients who presented their plan and asked for the office to sign a contract with their new insurance. It turns out that the doctors offices had not signed up with this company on purpose, due to the way the plan did business. Anxious to learn if things might have changed, one doctors group undertook a survey of medical practices in other areas that were already working with the plan. They learned that working with this plan was a disaster. Here are some of the specific problems they uncovered:
  • Doctors offices were forced to call customer service lines that were almost always busy, making it difficult to ask questions and get assistance
  • Customer service would frequently "transfer" calls which then became disconnected, starting the cycle of trying to get through again.
  • Customer service would frequently say they are going to reprocess a claim that was "lost" but then it would not happen
  • Most customer service calls are handled from India or Jamaica, by individuals who could not make a decision or really help. Often there is a lack of understanding from the person due to language barriers.
  • Payments for doctors services were artificially low, and grouped services together, only paying for one of them
  • Large, multispecialty clinics that could profit from expensive tests and procedures signed up and could afford the losses in primary care because they were able to make it up on their high ticket items, but the primary care clinics could not make it pay
  • The company's corporate practices often drove a wedge between the patient and the physician on several levels such as:
    • Inefficient claims process that loses claims but insists they were never billed and then blames the doctors office to the patient who complains
    • Requirements for multiple pre-authorization requests from the doctors office, even for routine care, but then hours are wasted trying to get through. An example is the requirement that the doctors office call them when a patient is in the hospital or is diagnosed as being pregnant. If this is not done "right away" then the later claim for care will not be paid
    • The plan created a business climate in the area that reduced medical insurance plan availability, since the other plans could not compete with the artificially low prices
    • Some states have already enacted legislation against this company because of some of their "predatory" business practices
The particular group in question decided once again not to participate with the plan, because to do so would jeopardize their own business and encourage employers to choose the plan. They do try to help their patients, however, by submitting a bill to the insurance company on behalf of the patient. If the claim is not paid, they then transfer it to the patient who gets to deal with their company directly to try and work things out.

Behavior like this from insurance companies is one reason why we have 50% less medical school graduates choosing to go into family medicine than we had when I made that choice in 1975. I believe that employers and citizens need to be more aware of how their choices affect the health care delivery system that they depend on for their care. Our health care "system' is a mess, precisely because of nonsense like this.