Posts Tagged ‘Specialists’

9 Things to Know About Patient-Centered Medical Homes in 2014

April 29th, 2014 by Patricia Donovan

Having established a firm foundation by providing over two decades of patient-centered care, the medical home model is poised for a makeover, expanding into medical neighborhoods and opening the door to specialists’ enhanced role in care coordination—two new metrics documented in the seventh comprehensive Patient-Centered Medical Home (PCMH) survey by the Healthcare Intelligence Network (HIN).

Here are nine benchmarks gleaned from the 2014 PCMH survey:

  • The annual percentage of respondents implementing the medical home model continues to rise, with a high of 58 percent reporting PCMH adoption, up from 52 percent in 2012, when the survey was last conducted.
  • The percentage of respondents with at least a fifth of patients assigned to medical homes more than doubled in the last two years, from 27 to 50 percent.
  • Today’s medical home is especially welcoming to Medicaid beneficiaries, who were targeted by only 3 percent of medical homes in 2012 but now are included in 37 percent of respondents’ patient-centered approaches.
  • Prepared to take their medical homes to the next level of care in the year to come, almost half—48 percent—have joined or expect to join a medical home neighborhood, defined by TransforMED&#8480 as “a strong foundation of transformed primary care practices aligned with health systems and specialists to ensure that care is maximally coordinated and managed.”
  • At the same time, 37 percent of 2014 respondents identified practice transformation, or the process of adopting the attributes of the patient-centered medical home model, as the most formidable challenge of medical home creation.
  • In new metrics from this year’s survey, nearly half of respondents (46 percent) include specialists in their patient-centered medical homes.
  • With an eye toward care coordination, the inclusion of case managers in medical homes jumped from 56 percent in 2012 to 76 percent in 2014.
  • Today’s medical homes are a little more crowded, with three-quarters of respondents reporting 21 or more physicians participating, up from 58 percent in 2012.
  • Undaunted by recent studies to the contrary, all 2014 respondents with medical homes believe the model can reduce cost and improve care delivery.

Excerpted from 2014 Healthcare Benchmarks: The Patient-Centered Medical Home.

Predictors of PHO Longevity and Financial Success

April 15th, 2014 by Patricia Donovan

Today, value-based payment models encourage hospitals and physicians to work together and make each more accountable for the other’s actions in a physician-hospital organization (PHO). But what are predictors of PHO longevity and financial success?

Here, Healthcare thought leaders Travis Ansel, MBA, manager of strategic services, Healthcare Strategy Group, and Greg Mertz, MBA, FACMPE, director of consulting operations, Healthcare Strategy Group, debate the question.

Response (Greg Mertz): It’s pretty evident that no one entity is going to be able to meet the needs of the population. If you’ve got a hospital that employs physicians, there’s an excellent chance that the employed physician network isn’t the total answer for caring for the population. They’re going to have to embrace non-employed physicians, other specialties, larger based primary care. Some entity is going to have to be created to make that happen.

But the PHO is an excellent model. Basically, it creates a collaborative entity that can bring in hospitals, employed physicians, non-employed physicians, ancillary providers. The PHO this time is something that is going to be necessary. Value is inevitable. I don’t see any reason that it would not have great longevity.

Response (Travis Ansel): I definitely agree. I think the biggest predictor of long-term success is the culture, but it’s going to be how the governance of the PHO is set up. It’s going to be giving the physicians, both employed and independent, a real voice in the organization and getting their expertise leveraged going forward. That’s going to be the biggest predictor. Beyond that, a willingness to experiment.

We’re in a situation now where organizations can’t really afford to sit on the sidelines for too long with all the different models that CMS and private payors are putting up in order to encourage shared risk between providers and hospitals. A willingness to experiment would be another key to success in my mind because it’s really the only way to learn how to be successful in this new environment, how to get involved in it and not hang on to the current FFS environment until it withers and dies.

Excerpted from Essential Guide to Physician-Hospital Organizations: 7 Key Elements for PHO Success.

How to Engage Specialists in the Patient-Centered Medical Home

April 1st, 2014 by Patricia Donovan

Primary care's relationship with specialists will influence quality and reimbursement.


Florida Blue’s primary care focused pay-for-performance program transitioned in 2012 into a statewide patient-centered medical home (PCMH) initiative. Here, Barbara Haasis, RN, CCRN, senior clinical lead for quality reward and recognition programs at Florida Blue, describes the role of primary care in engaging specialists in the PCMH program.

Engagement of specialists happens through the primary care physician (PCP). The PCP will be judged on the total cost of care, and his percentage of the shared savings is based on working with specialists that are efficient, and that report back to him or her, so that they are aware of what is going on. That is the development between the PCP and the specialist. They have to go to a specialist in the network, but we are not specifying who.

There is a huge incentive for the PCP, because when we look at a member’s total cost of care, we are looking at inpatient/outpatient, specialty, primary, lab, x-ray, total cost of care—it is everything. If there are two specialists, and one orders every test under the sun, whether it is needed or not, and the other goes into the ER to see the member and takes care of them efficiently and effectively, that primary care doctor is going to change his referral pattern to go to the more efficient. That is the incentive.

We are setting up other arrangements with specialists that will marry up to the PCMH. For example, we may do some kind of preferred cardiology network in the Orlando area into which the PCPs will probably refer. We cannot do that here. We have contractual language with many of our facilities and physicians that prevent us from doing any steerage.

It is up to the physicians to work through relationships to find the most effective for their practice.

Excerpted from: New Models in the Patient-Centered Medical Home: Incentives, Infrastructure and IT to Support Accountable Care

Pioneer ACO to Specialists: If the Care Coordination Role Fits, Wear It

September 24th, 2013 by Patricia Donovan

Monarch HealthCare took top honors in quality performance in year one of the CMS Pioneer ACO program.


As far as Medicare beneficiaries are concerned, it’s time for healthcare to acknowledge specialists as principal caregivers of the chronically ill, advises Monarch HealthCare, a top-performing CMS Pioneer ACO.

Monarch came to this realization in year one of participation in CMS’s Pioneer ACO program, when it discovered that 70 to 80 percent of office visits by its 14,000 accountable care organization (ACO) patients were to specialists.

“We have to start treating [specialists] like a primary care provider (PCP), especially for those patients that are chronically ill, where it is actually appropriate that a cardiologist is the primary care giver for a patient with CHF and coronary artery disease (CAD),” said Colin LeClair, Monarch HealthCare’s executive director of ACO.

Engaging and incentivizing specialists in its ACO are two key facets of Monarch’s year three performance strategy, noted LeClair during a recent webinar on Medicare Pioneer ACO Year One: Lessons from a Top-Performer. Going forward, Monarch plans to tap patient data from specialist encounters to enhance its care management and quality improvement efforts.

Despite its regret at not engaging specialists earlier, Monarch’s Pioneer ACO has plenty to be pleased about at the outset of year two, in which the number of ACO-attributed patients has swelled to 22,000 patients.

In terms of quality performance, Monarch, the largest IPA in Orange County, Calif., was year one’s top scorer in several patient-centered metrics in the Pioneer ACO program, and the second highest performer in the area of medical cost reduction — a result largely driven by reductions in hospital and skilled nursing facility (SNF) utilization and unit costs, noted LeClair.

Monarch is one of 32 originally selected CMS Pioneer ACOs. Today, 23 remain in the program.

During the 45-minute program, LeClair outlined Monarch’s six-step ACO implementation strategy, a patient-centered approach built around risk stratification, ACO team-building, and care management. Trial and error during the first year yielded some interesting findings, such as the optimal time to engage a patient, he said.

Among the four success drivers LeClair shared was a coterie of Web-based population health management tools Monarch developed for its ACO team, he said, that are supported with Web and face-to-face training.

One such tool is the annual senior health risk assessment (ASHA) reviewed by the patient and doctor during the Medicare Annual Wellness Visit. The free annual well visit provides an opportunity to identify key risk factors, perform screenings and reconcile medications.

Unfortunately, the new CMS benefit is largely unfamiliar to patients, LeClair added.

Another year one lesson learned was the value of the office staff in ACO rollout. As Monarch tweaks its ACO architecture, it is considering incentivizing the office staff as well. “Too often, incentives are focused on the physicians, and the office staff actually drives most of the work to support the ACO population,” said LeClair.

In closing, LeClair said Monarch remains committed to the ACO model, and as it looks ahead to year three, it hopes to identify mini-networks of physicians, explore episodic or bundled payments, and partner with hospitals, SNFs and ancillary vendors to reduce avoidable utilization.

Click here to listen to an interview with Colin LeClair.