Our health care system is in crisis, and this crisis is creating remarkable opportunity for the chiropractic profession. In fact, the most notable opportunity is something you probably have never heard of: the patient-centered medical home (PCMH) model. If implemented, the PCMH model could restructure the entire health care delivery system, take chiropractors out of the fringe and place them in an integral role in patient management. But there's a catch: We need to embrace the technology that will make it possible.
Times Are Changing
Times are changing. That was the theme of last month's column, where I explored three predictions regarding chiropractic and electronic health records (EHRs). Those predictions, made in 2005, were as follows: More chiropractors will embrace EHR, Medicare will increase audits of chiropractors, and EHRs will be mandated. The first two have already come true. As for the third, while there's no official federal EHR mandate, an unofficial mandate will come through billing and documentation requirements for Medicare, even if no official mandate is made.
As the medical home model relies on the quick exchange of health information, the PCMH model could provide another source of pressure for an unofficial EHR mandate in our very near future. It shouldn't be seen as pressure, but rather as an opportunity to expand chiropractic to the masses under the basic national health care plan. The PCMH model is one more sign that times are changing.
What Is the PCMH?
The patient-centered medical home model, medical home model, and PCMH all describe the same thing: a reorganization of the health care system with an army of professional case managers or "health coaches" empowered by electronic health care information. The PCMH model centers on the patient. It is patient-centric driven health care. In order to effectively manage a patient's overall health care, the single provider needs all the information at their fingertips to do so properly.
It can only be effectively accomplished, particularly if you were to manage hundreds of these cases, with the newly emerging resource called a Health Information Exchange (HIE), where health history and recent health care diagnostic test data and other relevant health care information is stored and accessed for patient care, as empowered by the widespread use of EHR systems. Think of it as a network of EHRs talking to each other and updating each other about a patient's treatment and progress, regardless of discipline.
There are around 130 pilot sites all over the country where the PCMH model is currently being tested, and so far, the results are promising. Hospital test sites are showing amazing cost savings, even with the added cost of hiring more personnel for information management. That's because fewer visits are being occupied by follow-ups for test results and other paperwork. Instead, more doctor-patient interaction actually involves real doctor visits (assessment, diagnosis, etc). And insurance companies are seeing cost savings in fewer hospital re-admission rates. Fewer patients are falling through the cracks. Patients are becoming more involved with their care since they are actively and routinely communicated with via technology and see their results immediately.
PCMH and the Chiropractic Cameo
If you haven't heard of the PCMH model yet, you're not alone. In the fall of 2009, I attended a symposium on PCMH sponsored by the University of Iowa College of Public Health. Out of 200 attendees at this medical conference, I was only one of three chiropractors present. It was unfortunate that only a few chiropractors were there, because our profession made an interesting cameo during the proceedings.
Iowa State Senator Jack Hatch, key author of medical home legislation in Iowa, made a point of mentioning chiropractic during the symposium. The context of his conversation was making proper referrals within the PCMH model, in which he encouraged the medical doctors present to make use of chiropractic care in patient management because of the evidence for the use of chiropractic for back pain.
His point was that within the PCMH model, management of patient treatment protocols with the best evidence will take center stage. It will be the responsibility of the case manager to inform patients of all of their options and the advantages associated with each. This is a key component to all models of the PCMH.
Talk about a change in the delivery of health care. Providers being required to give patients treatment options that have evidence-based outcomes will make patients aware of their options in choosing treatment for a given diagnosis.
Chiropractors as Medical Home Managers?
Iowa's PCMH legislation is one of the primary models for the potential use of the medical home concept across the United States. Like Senator Jack Hatch's reference to chiropractic care during the symposium, what is interesting about the medical home system in Iowa is its specific inclusion of doctors of chiropractic. Under Iowa law, only four professional disciplines can be case managers: MDs/DOs, PAs, ARNPs and DCs. These providers can have ancillary qualified staff provide much of these services under their supervision. For example, RNs currently provide much of the follow-up calls and dissemination of educational material to the patient in the pilot study medical homes.
While the concept of being a health care case manager or health coach isn't attractive to all chiropractors, it's in the skill set of many of our colleagues. Knowledge of medication side effects, physical examination skills, and the ability to communicate with other health care professionals is critical to the success of the DC fulfilling the medical manager role. Chiropractors will be joining the ranks of primary care providers as medical home managers, helping to coordinate care with providers across the health care spectrum. Many chiropractors are proud of their abilities as specialists in truly conservative, natural health care. So, wouldn't it be great to have colleagues in your state helping to organize the PCMH model in your community? We should encourage as many DCs as possible to step into these roles.
Why the PCMH?
The fact is simple: For small businesses, families and local governments, our current health care model is not sustainable. We only have another decade before health insurance premiums will occupy 20 percent of all family spending per the GNP projections. Yes, there are arguments for tort reform and other cost-saving measures, but everyone knows that what's needed is a level of efficiency that isn't being achieved in our current model. The system is too big and slow to last; that is why PCMH is being seen as a solution for wasted spending - one that should improve patient outcomes if done correctly.
Another simple fact is the growing shortage of primary care physicians in an era of aging Americans. In the state of Texas alone, it has been estimated that they will need 40,000 additional new physicians by 2020 to meet the needs of the population. I believe it will be impossible for them to meet this need with only MD primary care providers. I think it's enough to point out that the PCMH model holds a lot of hope for health care planners who know that someone needs to come along and fill the provider shortage gap. That someone may be a nurse practitioner or a PA. Or it may be a doctor of chiropractic hooked up to a health care information exchange, acting as a medical home manager.
A Chiropractic Moment
Without doubt there are many doctors among us who would never want to be a medical home manager. And yes, much of what's going to happen with the PCMH model hasn't been settled yet. (By the time you read this, a version of health care legislation will likely have been passed in the House, Senate or both.) Yet, for a profession that continues to be underutilized, needing more cultural authority, the opportunity offered by the medical home model could be revolutionary. Following the successful use of chiropractic in the Veterans Administration, the PCMH could provide a VA-like opportunity in every community across the United States where a chiropractor takes the responsibility of a medical home manager.
Still not convinced that chiropractic could play a role in the medical home model? What about this: 45 percent of the U.S. population has some sort of chronic condition, accounting for 75 percent of all health care spending. Chronic conditions drive up health care costs in the absence of state-of-the-art coordination of care to catch redundancies. Care for chronic problems must also address the underlying lifestyle factors that increase the incidence of chronic disease. Our health care system is begging for a conservative physician who can address functional and lifestyle problems in order to drive down costs. If that person can also lead coordination of care via PCMH, that's even better.
Change with Technology
While the details of how the PCMH will be implemented are still being studied, one thing is certain: It won't happen without widespread use of interoperable electronic health records and a constant exchange of health care information. As a health care provider, not being able to interact with this exchange is going to cut you out of the future of patient management, regardless of whether you want to be a medical home manager or not.
Right now, more than 130 health care sites are experimenting with a PCMH model that includes electronic documentation and coordination of care. Will you implement the technology it takes to include your care results on your patients' health? For the sake of your patients' wellness, for better efficiency in managing your patients, for the sake of reducing health care costs, and for the sake of our profession gaining more cultural authority and exposing more people to the benefits of chiropractic, it's time we stepped up and led the country in the metamorphosis needed to advance the delivery of health care.
Many relevant diagnostic signs are not performed deliberately by the examiner or by the patient at the examiner’s direction. They are observed as the patient reacts to their condition. Fortin’s finger sign, Minor’s sign, and Vanzetti’s sign are three examples of this principle.
On Feb. 1, 2024, two more legislators – John R. Carter (R-Texas) and Robert “Bob” Good (R-Va.) – co-sponsored the Chiropractic Medicare Coverage Modernization Act of 2023, bringing the co-sponsor total to 155, two more than the total achieved over the entire two-year congressional cycle in which identical legislation last appeared (2021-22).
While working at the Lovelace Medical Center in Albuquerque, N.M., one of the primary care physicians stated that imaging every patient prior to receiving chiropractic was not medically necessary. It was at that point I reconsidered the need for the imaging of every patient to avoid malpractice.
