Medical Professionals, Insurers Take Lead in Model Adaption
Perhaps stymied by pressure from managed care organizations not to pursue change, Tennessee lawmakers haven’t taken formal steps to incorporate the Patient Centered Medical Home (PCMH) concept into the state healthcare plan. At least, certainly not to the extent that early adapter North Carolina implemented with its highly successful Community Care of North Carolina (CCNC) program nearly two decades ago.
Instead, medical professionals and insurers statewide have taken the lead in the PCMH movement, introducing efforts to reduce emergency room use with promising results.
Initiated by the state's hospitals and sanctioned by the Tennessee bureau that oversees it, TennCare,Tennessee'smanaged-care Medicaid program, has initiated a plan to decrease emergency department dependence. Independently, medical practice consortiums across the state, established to boost bargaining power, provide physician members with incentives to do the same.
On Sept. 1, Amerigroup launched “Amerigroup On Call,” a 24/7 nurse triage and referral service for Medicaid and Long Term Care (LTC) participants enrolled in Amerigroup’s Tennessee health plan who need urgent care. Depending on the patient’s symptoms, nurses may schedule an urgent care appointment with the member’s primary care physician, schedule a phone consultation with a physician, refer the member to urgent care centers or clinics within its network, or refer the member to the nearest emergency room. Amerigroup has also taken steps locally, such as narrowing down its physician network in Davidson County and steering patients to larger practices.
For the most part, these efforts have been embraced by the Tennessee Medical Association (TMA), which expresses in its position statement on healthcare reform that the PCMH model would strengthen the physician-patient relationship and should be emphasized in any reform plan.
“Tennessee was employing the medical home concept before it was cool,” said James Batson, MD, a pediatrician with Cookeville Pediatric Associates in Cookeville, Tenn., and chair of TMA’s Young Physicians Section. “As a concept, primary care providers have been the medical home for Tennessee patients without a lot of structure for years. We’re the go-to providers for most patients as opposed to the non-ideal world of drive-thru clinics. We build relationships with patients over time, our practices are patient-centered, and the majority of healthcare needs are met by primary care providers and their staff.”
However, Batson noted, as technology has advanced and cost-cutting measures are being implemented as healthcare reform takes shape, putting some structure on the PCMH model isn’t a bad idea.
Without legislatively mandated change, several obstacles exist — geographic location and the mindsets of physicians and patients — before medical practices can fully embrace the PCMH model.
“The medical home concept is a bit of a challenge in rural areas,” Batson explained. “It’s easier for a primary care provider to incorporate the model in a metro area with a lot of specialists around. In a rural area like Cookeville, where you have to go about an hour and a half in any direction to find a pediatric specialist, it’s a little more difficult.”
Batson’s practice, which he joined in 1999, has kept up with Cookeville’s slow and steady growth. Lloyd Franklin, MD, established the solo practice in 1983. When Batson joined him, Franklin built a new practice facility to accommodate four providers. In December 2008, Franklin opened a new building that tripled the square footage of space to house five pediatricians and three nurse practitioners.
In late 2006, the practice implemented an electronic medical records system. “The problem with health information is that everybody does it their own way, and we don’t yet have ideal communication across electronic channels, though it’s moving in that direction,” said Batson.
Adapting early to the trend of larger practices and EMR implementation, which Batson calls “just good business sense,” puts Cookeville Pediatric Associates in line with the PCMH model.
Motivating a majority of practices to make similar moves may be thwarted by the physician mindset of “we’ve heard it all before,” combined with financial reality, said Batson.
“When I was in medical school and training in the early to mid ‘90s, the big push at that point was the patient-centered practice, and primary care providers were going to be the gatekeepers,” he explained. “You weren’t going to be able to get any referrals until the PCP said yes or no. That model fell out of favor several years later, showing that the best laid plans don’t always work. Sometimes, it’s in the patient’s best interest to be able to call a specialist rather than go through the primary care provider for every little thing. Also, as time has gone on and medical debt has risen to significant proportions, you’re seeing a swing to specialty care, where reimbursement rates are more favorable and student loans can be paid off faster. It’s a bit of an uphill battle for primary care providers.”
Wrinkles need to be smoothed out before patients will be motivated to willingly comply with program mandates, said Batson
“People don’t like to be told what they can’t do, and there are some situations you just can’t fix, like stopping that first-time mom with a baby crying all night from going to the ER,” he said. “The programs must be designed where patients aren’t under the impression their options are being limited. When that’s done, the programs can work well.”