Is a Patient-Centered Medical Home in Your Future? It Is for Your Patients
By Scott Munsterman, DC, FICC
There is an undercurrent established and ready to carry your patients either away from your practice or toward it. That movement is called the Patient-Centered Medical Home (PCMH).As described by the Agency for Healthcare Research and Quality, "Its components include patient-centered care with an orientation toward the whole person, comprehensive care, care coordinated across all the elements of the health system, superb access to care, and a systems-based approach to quality and safety. Ultimately, these components are intended to improve patient outcomes – including better patient experience with care, improved quality of care (leading to better health), and reduced costs."
Now that sounds great, but what does it really mean to chiropractic physicians? Let's start with the main driver of the PCMH: the primary care physician. According to the National Committee on Quality Assurance (NCQA), an organization that credentials medical homes, a primary care physician is an MD, DO, NP or PA. While the DC is not included on that list, according to the Joint Commission chiropractors are allowed to serve on the patient's interdisciplinary team.
Occurring right now across the nation, medical practices, hospitals and health systems are working diligently to organize themselves into this new model. Don't take my word for it; Google "medical home" and see for yourself. The allopathic community has figured out how the medical home will dovetail into the new reimbursement environment, which includes accountable care organizations.
The key to the medical home is this: Medical homes will be driven by a primary care physician who will make the decision where the patient needs to go and whom they will need to see. Outcome measures will be used as data points marking the performance of care within the practice. This performance will be used to determine reimbursement and will also be compared to other practices organized as a medical home. Back in the 1990s, we called this a gatekeeper model of managed care. It is amazing to me to see how these concepts keep coming back. But will this new model save the health care system money? Actually, yes.
A recent article published in the Journal of the American Board of Family Medicine, supported by a grant (R18 HS06167) from the Agency for Healthcare Policy and Research (now known as the Agency for Healthcare Research and Quality), concluded, "Patient-centered care was associated with decreased utilization of health care services and lower total annual charges. Reduced annual medical care charges may be an important outcome of medical visits that are patient-centered." This article is the first of many that will begin to support something the chiropractic profession has stood for since its inception: that a holistic approach to patient care from a conservative physician not only saves money, but also provides the best-quality care for the patient.
Wellness and self-management, along with other tenets of the PCMH, characterize the principles we as DCs have practiced daily with our patients for over a hundred years. Let's dissect this new model and assess it more closely. I think you will be surprised at how the proposed functions within a medical home may already resemble your practice.
Patient Access and Continuity
Many of us have a policy-and-procedure manual for our offices, but does it outline a clear path for patients to gain access to our schedule the same day they call? In the evenings? On weekends? Does our current policy provide a mechanism to track these calls or at the very least, monitor occasionally to make sure patients have access to you, the physician? As someone who has practiced for over 25 years, training front-desk staff to "do their best" to get patients scheduled was a top priority. As DCs striving to grow our practices, this element of the medical home is what many of us do already. We just need to document our policy and measure our performance.
Identify and Manage Patient Populations
Our profession continues to struggle with documenting our care. We have been after the quick and easy processes and it has hurt our profession's ability to become respected in the third-party-payer environment. Well, data collection will be even more critical, but with the advent of EHRs practices will be able to harness data and report it in a meaningful way and be able to comply with data collection requirements. Identifying the most frequent diagnoses, conditions, and patient risk factors are important as the practice will be responsible to manage these populations from not only a treatment perspective but also from a preventive or wellness aspect. That's right, you are now in the business of wellness. Within the medical home setting, health promotion and wellness are valued commodities and the primary care physician must exhibit qualities of this trade. As a chiropractic physician, you have a natural strength in this area because of your training and holistic, clinical approach.
Plan and Manage Care
Physicians in the primary care "driver" seat of the medical home will need to have guidelines in place for the treatment of the top three clinical conditions treated within the practice. Care coordination will be a function as well – helping the patient find the health care they need. Maybe I am biased, but chiropractic physicians always do the best in this area. That is one of the reasons we are so successful at our patient relationships. We build trust with the patient over time as we show them repeatedly we care about them and make decisions that keep them in the center of the process. I can't tell you how many times each day in practice I would hear a patient tell me, "I wasn't sure if you could help me or not, but I thought I would start with you first because I know you will tell me the right thing to do." Many of you also hear those words every day and it is a sign that our patients expect us to lead and navigate them through their health problem, whether we can directly help them with our care or not.
Provide Self-Care Support and Community Resources
Let's face it - our profession is the best when it comes to helping patients understand their health problem. We take the time to talk with them, develop a relationship with them and see them through their problem. We spend time showing them exercises, counseling on nutrition and diet – all in an effort to help them achieve a sense of personal responsibility for their health care that will benefit them in the long run. And we give this advice freely during patent visits and in public lectures. Now the medical home model promotes this as well.
Prescribing and Drug Interactions
How many times in practice have we run into a patient who is on many different types of prescriptions and you can't help but believe there are interactions involved? EHRs will become very helpful in tracking these potential interactions and we can contribute to the patient's overall health in the process. In addition, nutritional advancements are being made that will allow us to share those types of opportunities with our patients as alternatives to a pharmacological approach.
Track and Coordinate Care
Many of us enjoy the privilege of being able to order outpatient diagnostic tests at a local hospital or stand-alone diagnostic facility. MRIs, CTs and bloodwork are among the tests our profession typically orders. As we know, timely referral and follow-up with the patient to review the results are important. This must be coordinated within the medical home setting.
Likewise, referral to an internal or external provider or specialist requires identifying those providers or specialists who work best with you in your practice with your patients. A track record with other providers (or as the AHRQ calls them, "good neighbors") is helpful in the coordination of care to promote an efficient and timely process.
The medical home setting may use an information technology platform to help keep patients from falling through the cracks in the busy practice. In this day and age, many of us have become accustomed to electronic communication. The PCMH embraces technology advancements and leverages the secured communication capability between the clinician and the patient, as well as the interaction among care team members.
Measure and Improve Performance
Performance measurement is where the rubber will hit the road, and chiropractic physicians have nothing to fear here. As a matter of fact, gathering the outcomes from care for the top three conditions treated within the chiropractic practice (low back pain, neck pain and headache) will be a great opportunity for chiropractic care to be compared to other medical homes that treat those very same conditions. By positioning chiropractic care in the marketplace, not chiropractor against chiropractor – but rather chiropractor against all providers for these conditions, our profession will shine. It will gain recognition and it will have its opportunity to succeed in the new marketplace of health care.
Our profession has most certainly been challenged throughout our history with being accepted on many different fronts; the early days when our chiropractic colleges were accepted in the accreditation process, state law recognition and licensure, federal recognition in Medicare, the AMA antitrust issue and more recently the past few decades with third-party reimbursement. We have consistently averaged treating around 10 percent of the population, always hoping we could reach the other 90 percent.
What will it take to reach the other 90 percent? A new marketplace in health care is opening up right in front of our eyes. Are you getting yourself and your practice ready? I believe this could be the greatest opportunity for our profession to shine. More to come on this subject. Thanks for listening.
Dr. Scott Munsterman, a 1984 graduate of Northwestern College of Chiropractic, is past president of the South Dakota Chiropractic Association and practiced in Brookings, S.D., until 2009. He served two terms as mayor of Brookings (2003-2009) and was a Republican candidate for S.D. governor in 2010. Dr. Munsterman is now the CEO of the Best Practices Academy, based in Brookings.