Making Medical Homes Self-Sustaining

In the future health insurance companies may reward patients who maintain their health through employee health programs that pay people to get active. For now, however, the future of reimbursements lies within the provider's ability to keep a patient healthy.

That is why the medical home, has become the model to add to your hospital, health system or practice. Indeed, there are results (and dare I say an opportunity for revenue) in this patient-centric model, even now, before the reimbursement system changes occur.

Earning revenue from this model requires the help of the payer. For instance, six New York health plans – Aetna, CDPHP, the Hudson Health Plan, MVP Health Care, UnitedHealthcare and Empire BlueCross Blue Shield recently provided $1.5 million in incentive payments to 236 separate primary care physicians in 11 practices for achieving patient-centered medical home recognition by the NCQA.

They aren't the only ones, either. More and more health plans nationwide are offering some sort of incentive or bonus to providers who create a medical home—so if you haven't checked with your payers you may want to do so.

Unfortunately, not every hospital, health system, or practice that opts for a medical home will get the benefit of incentive dollars. In these instances, the trick is to create at least a self-sustaining medical home that functions under the current reimbursement structure, and doesn't lose money. Because providers of all sizes will want to have a medical home in place within the next couple of years, however, you don't want to create it at the financial expense of your current practice.

How is this accomplished? In a highly motivated practice where there is enough traffic that wellness can be practiced, practices can take on more cases, do more preventative care visits, and the dollars that come in can help support the program.

Because the patient-centered medical home is such an important part of the future of healthcare, this week and next week I'm going to take a look at two Maine patient-centered medical home pilot programs that are approaching this task and some of the results they are finding.

First up is Southern Maine Medical Center (SMMC) PrimeCare Physicians in Biddeford, ME, a multi-specialty group practice started in 1996 with over 40 physicians. The organization is also part of the 150-bed Southern Maine Medical Center. The practice's overarching goal is to preserve the quality of the personal relationship between patient and doctor. To that end, it decided to join the Maine Patient Centered Medical Home Pilot in 2008 and after being accepted got the program off the ground in 2009.

"It is in our plan that we achieve [NCQA] certification and that all our primary care offices are patient-centered medical homes," said Vicki Lyons, vice president of physician services for SMMC PrimeCare Physicians.

Using the existing staff, the practice, which serves 8,900 patients, formed small leadership teams to assess which areas to tackle. First on the list for improvement was patient access and communication. SMMC wanted to create a practice where patients who asked to be seen immediately, could be seen the same day.

The team started by measuring where the practice was in terms of access—a 12-15-day period was common—and brainstorming on how to improve it. Lyons says by eliminating structured scheduling templates and creating flexible templates and contingency scheduling plans, they were able to significantly reduce how long it took for a patient to be seen.

The practice also used IHI scheduling strategies and within one year patient access was reduced to three days, though the team is still working to bring that to one day.

"Access has been a great success for us," says Lyons. "You have to get a handle on supply and demand. How many patients are calling in for appointments for the same day? And once you do that, you need to create a contingency schedule to handle [clinical staff] vacations."

What the practice found was that patient access influenced other areas the teams were trying to address, such as care management. Although the practice had a nurse practitioner already in place when the pilot started, the practice added two care managers through the Physicians Health Organization of Maine.

Already paid for through the practice's dues to PHO, these two individuals began working in the office two days a week to contact chronically ill patients, such as those with diabetes, depression and heart issues.

"Our goal was to keep these people out of the ER. We asked, 'How can we accommodate these individuals – to see the ones that need support more often? By improving the patient's access, and getting them in to see the primary care physician or nurse practitioner when they need it."

However, after several months of the care managers contacting patients over the phone, the group realized that this model wasn't working for them. Lyons says because the practice had so many chronic disease patients, the team couldn't keep up with the patient demand. So the organization changed tactics. First, a full-time nurse practitioner was added solely to do chronic care outreach.

Second, PrimeCare Physicians opened a weekend clinic to help meet the patient demand and to reduce ER utilization. Moreover, the practice began scheduling more preventative care visits and the organization increased areas such as mammography to nearly 80% and the colorectal screenings to nearly 60%.

"As a pilot we are working to prove that this does pay off. So when we talk about reduced utilization in the ER and reduced readmission, we know that's where we need to be, but we're still tracking this piece," says Lyons. "We are also following our chronically ill patients and seeing that they come in for all the required tests and following up to see that they do it."

Though data on reduced ER use is not yet available, Sue Butts-Dion, director and quality improvement specialist for the Maine Patient-Centered Medical Home Pilot says early data shows that some of the access work the pilot programs are doing across the state are resulting in decreased ER use. In the next few years the plan is to have more definitive metrics on this. 

As the practice has gone through this process, there have been several lessons learned—the care management area was just one of them. "It didn't work for us the way we tried it at first, so we changed it," explains Lyons. "Now our challenge is trying to sustain momentum and not take on more than we can handle."

As SMMC PrimeCare Physicians continues the patient-centered medical home pilot project, some funds are coming in from the effort. Along with seeing an uptick in the number of preventative care procedures and being able to schedule more patients, and in a timely manner, payers are also pitching in.

Organizations participating in the pilot receive a $3 per member fee from all but one payer in Maine.

"Maine has always been a state that's collaborative in nature. So when we started we had the right people come to the table with that collective, collaborative spirit. Naturally, there are expectations for this pilot. The payers have expectations too, they aren't doing this and not expecting anything in return," notes Butts-Dion. "But the good thing about the pilot is we are able to support these programs and help them get the funds they need."

Next week I'll take a look at how Penobscot Community Health Care in Maine is approaching its medical home and where it's finding opportunities to improve and change care without disrupting the bottom line.