AT HOME WITH THE SPE­CIAL­IST

On­col­o­gists and other spe­cial­ists launch­ing pa­tient-cen­tered med­i­cal homes

Modern Healthcare - - Q3 | 2014 HEALTHCARE MERGERS AND ACQUISITIONS REPO - By An­dis Robeznieks

Solo prac­tice en­docri­nol­o­gist Carol Green­lee is one of a small num­ber of spe­cial­ist physi­cians in the coun­try who op­er­ate their prac­tice as a pa­tient-cen­tered med­i­cal home, a model pi­o­neered by pri­mary-care doc­tors. She has ex­panded the med­i­cal home into a med­i­cal “neigh­bor­hood.”

From her of­fice in Grand Junc­tion, Colo., Green­lee stud­ies pa­tients’ med­i­cal records and ques­tions their other doc­tors so she is thor­oughly fa­mil­iar with their health is­sues be­fore they ar­rive for vis­its. She also con­sults with other doc­tors elec­tron­i­cally on dif­fi­cult cases, which of­ten makes it un­nec­es­sary for pa­tients to come in for vis­its to her of­fice.

The med­i­cal home con­cept has moved beyond pri­mary care. This pa­tient is re­ceiv­ing care at East­ern Maine Med­i­cal Cen­ter’s Maine Re­ha­bil­i­ta­tion Cen­ter in Ban­gor which has been rec­og­nized by the Na­tional Com­mit­tee for Qual­ity As­sur­ance as a Pa­tient-Cen­tered Spe­cialty Prac­tice.

But for now, she re­ceives no ad­di­tional pay­ments from in­sur­ers for th­ese pa­tient-man­age­ment ser­vices, de­spite hav­ing earned pa­tient-cen­tered spe­cialty prac­tice recog­ni­tion this year from the Na­tional Com­mit­tee for Qual­ity As­sur­ance. “We com­mu­ni­cate back with the pri­mary-care doc­tor after ev­ery one of our pa­tients’ vis­its,” Green­lee said. “But some of our pa­tients might not use a pri­mary-care doc­tor, so we have to look after them a lit­tle more.”

Green­lee hopes her NCQA recog­ni­tion will in­spire other small physi­cian groups to trans­form their prac­tices, and send a mes­sage to Medi­care and pri­vate in­sur­ers that they should fi­nan­cially re­ward doc­tors for of­fer­ing this higher level of ser­vice to pa­tients.

De­spite ten­sions be­tween pri­mary care and spe­cial­ist groups over what types of prac­tices should serve as med­i­cal homes, a grow­ing num­ber of spe­cial­ist prac­tices, in­sur­ers and health sys­tems are mov­ing to­ward the pa­tient-cen­tered spe­cialty home model.

The NCQA’s pa­tient-cen­tered med­i­cal home recog­ni­tion pro­gram has about 8,400 par­tic­i­pants, mostly pri­mary-care prac­tices. Its Pa­tient-Cen­tered Spe­cialty Prac­tice recog­ni­tion pro­gram, launched in March 2013, has got­ten off to a slow start, how­ever. Tampa, Fla.-based Health­Point Med­i­cal Group was the first to gain recog­ni­tion in Fe­bru­ary. Thirty other spe­cialty prac­tices have since fol­lowed. The list in­cludes 10 on­col­ogy, four en­docrinol­ogy and two car­di­ol­ogy groups.

The NCQA ex­pects in­ter­est among spe­cial­ist physi­cians to in­crease, though the group may have to re­fine its med­i­cal-home cri­te­ria to bet­ter fit with clin­i­cal ap­proaches and pa­tient char­ac­ter­is­tics of the dif­fer­ent spe­cial­ties. Leah Kauf­man, who heads the NCQA’s out­reach ef­forts, pre­dicted the pro­gram would grow when more in­sur­ers in­tro­duce pay­ment mech­a­nisms to re­ward the ex­tra work that goes with be­ing a med­i­cal home. “We’re start­ing to see some payer support,” she said. “They are in­ter­ested in car­di­ol­ogy, en­docrinol­ogy, on­col­ogy and some OB-GYN.”

Some on­col­o­gists also have adopted the med­i­cal-home model, which is based on the prin­ci­ples of en­hanced com­mu­ni­ca­tion and co­or­di­na­tion of care, ex­panded ac­cess through evening and week­end of­fice hours, as well as phone and elec­tronic con­tact, provider team­work, proac­tive as­sis­tance to help pa­tients man­age their own health, and con­tin­u­ous per­for­mance track­ing and qual­ity im­prove­ment.

At the New Mex­ico Can­cer Cen­ter in Al­bu­querque, CEO Dr. Bar­bara McA­neny cal­cu­lates that her med­i­cal home-style prac­tice model has re­duced the hos­pi­tal­iza­tion rate for the 7,200 can­cer pa­tients par­tic­i­pat­ing in the seven-state on­col­ogy med­i­cal-home demon­stra­tion project she leads from 25 to 18 days per 1,000 pa­tients. Her Com­mu­nity On­col­ogy Med­i­cal Home, which she calls Come Home, has es­tab­lished evening and week­end hours so can­cer pa­tients can come in and see fa­mil­iar providers in a com­fort­able set­ting.

Pa­tients “are thrilled with the idea of not hav­ing to go to the emer­gency depart­ment for eight hours or more and then be­ing seen by some­one who’s un­fa­mil­iar with them,” said McA­neny, who is also chair of the Amer­i­can Med­i­cal As­so­ci­a­tion board of trus­tees. “If you know your re­main­ing num­ber of days is limited, the last place you want to spend them is wait­ing in emer­gency.”

But the pri­mary-care physi­cian groups that spear­headed the med­i­cal-home move­ment say spe­cial­ist prac­tices gen­er­ally can­not func­tion as true med­i­cal homes. They ar­gue that one of the core prin­ci­ples is a “whole-per­son ori­en­ta­tion,” and that spe­cial­ists don’t fit with that ori­en­ta­tion given their fo­cus on par­tic­u­lar or­gan sys­tems and dis­ease con­di­tions.

“If (spe­cial­ists) are see­ing some­one ev­ery day, they’re prob­a­bly man­ag­ing an acute prob­lem, but that doesn’t con­sti­tute a pa­tient-cen­tered med­i­cal home,” said Dr. Reid Black­welder, pres­i­dent of the Amer­i­can Academy of Fam­ily Physi­cians, which, along with the Amer­i­can Academy of Pe­di­atrics, the Amer­i­can Col­lege of Physi­cians and the Amer­i­can Os­teo­pathic As­so­ci­a­tion, de­vel­oped the med­i­cal-home joint prin­ci­ples.

NCQA rec­og­nizes med­i­cal home

In re­sponse, Dr. John Spran­dio, whose nine-doc­tor on­col­ogy and hema­tol­ogy prac­tice in the Philadel­phia area be­came the first non-pri­mary-care prac­tice rec­og­nized by the NCQA as a pa­tient-cen­tered med­i­cal home, said on­col­ogy prac­tices are fully ca­pa­ble of meet­ing the med­i­cal-home cri­te­ria in that they pro­vide acute, chronic, pre­ven­tive and end-of-life care. He added that car­di­ol­o­gists, nephrol­o­gists and rheuma­tol­o­gists also pro­vide chronic-care man­age­ment to their pa­tients over a long term.

McA­neny agreed. “When a per­son gets di­ag­nosed with can­cer, all their other prob­lems go on the back burner and can­cer be­comes their main fo­cus,” she said.

Dr. David May, a board mem­ber of the Amer­i­can Col­lege of Car­di­ol­ogy, said that for pa­tients with heart trans­plants or end-stage re­nal dis­ease or who re­quire com­plex phar­ma­col­ogy, spe­cial­ists are the heart of the care team. “In that en­vi­ron­ment, it should be the pri­mary-care physi­cians who are the con­sul­tants,” he said.

Some in­sur­ers are mov­ing ahead with spe­cial­ist-based med­i­cal homes de­spite the pro­fes­sional dis­agree­ments. Aetna is launch­ing an on­col­ogy med­i­cal-home net­work on Jan. 1 as a pi­lot project, said Dr. Michael Kolodziej, Aetna’s na­tional med­i­cal di­rec­tor for on­col­ogy strat­egy. It will in­volve 20 to 25 on­col­ogy prac­tices and more than 100 pa­tients in At­lanta, Day­ton, Ohio, and Fort Worth, Texas. Aetna will fo­cus on pa­tients with breast, colon and lung can­cer be­cause those can­cers ac­count for 50% to 60% of pa­tients uti­liz­ing chemo­ther­apy. The in­surer hopes to im­prove the pa­tient ex­pe­ri­ence by man­ag­ing med­i­ca­tion

toxicity, re­duc­ing hos­pi­tal­iza­tions and trim­ming costs by 10% to 15%. While the num­ber of pa­tients is small, it’s enough to test the con­cept be­cause of high hos­pi­tal­iza­tion rates for can­cer pa­tients, Kolodziej said.

Spran­dio praised Aetna’s ef­fort over­all but dis­agrees with the in­surer’s fo­cus on only breast, colon and lung can­cers. That may cover most can­cer pa­tients, but those types of pa­tients are not the ones who use the most re­sources be­cause they tend to be younger, have more stan­dard­ized treat­ment pro­to­cols and ex­pe­ri­ence fewer ED vis­its, he said.

Pitts­burgh-based UPMC Health Plan, owned by the UPMC health sys­tem, which al­ready op­er­ates 384 pri­mary-care med­i­cal home prac­tices serv­ing 255,000 pa­tients, also is launch­ing a spe­cial­ist-based med­i­cal-home model. It will ex­am­ine which dis­ease states best lend them­selves to the model, said Sandy McA­nallen, se­nior vice pres­i­dent of clin­i­cal af­fairs and qual­ity per­for­mance for UPMC’s in­surance ser­vices di­vi­sion. UPMC Health Plan’s first such ef­fort will be headed by Dr. Miguel Regueiro, a gas­troen­terol­o­gist who is launch­ing a med­i­cal home ori­ented to in­flam­ma­tory bowel dis­ease for pa­tients with ul­cer­a­tive col­i­tis and Crohn’s dis­ease. McA­nallen said the prac­tice will take a team­based ap­proach and in­clude a pri­mary-care nurse prac­ti­tioner and a psy­chi­a­trist.

Among health sys­tems, the East­ern Maine Med­i­cal Cen­ter in Ban­gor has four spe­cial­ist prac­tices that have earned NCQA recog­ni­tion as pa­tient-cen­tered spe­cialty prac­tices, in­clud­ing its cen­ters for di­a­betes and en­docrine care, gas­troen­terol­ogy, vas­cu­lar care and re­ha­bil­i­ta­tion. Its can­cer care and women’s health cen­ters also have ap­plied for recog­ni­tion. “It is time-con­sum­ing, but it’s ab­so­lutely worth it,” said El­iz­a­beth Perry, East­ern Maine’s lead qual­ity an­a­lyst and physi­cian prac­tice ad­min­is­tra­tor.

“Vari­able” qual­ity ef­forts

But in­sur­ers’ recog­ni­tion of East­ern Maine’s med­i­cal home-based qual­ity ef­forts has been “vari­able,” said Dr. James Raczek, the sys­tem’s se­nior vice pres­i­dent of op­er­a­tions and chief med­i­cal of­fi­cer. An­them Blue Cross and Blue Shield, in par­tic­u­lar, pays above and beyond typ­i­cal of­fice-visit re­im­burse­ment.

McA­neny in Al­bu­querque re­ceived a $19.8 mil­lion Health Care In­no­va­tion demon­stra­tion grant from the Cen­ter for Medi­care and Med­i­caid In­no­va­tion to ex­pand her on­col­ogy med­i­cal home model to cen­ters in Florida, Ge­or­gia, Maine, New Hamp­shire, Ohio and Texas. Un­der the three-year project, par­tic­i­pat­ing on­col­ogy prac­tices will pro­vide 24/7 ac­cess, care man­age­ment, pa­tient ed­u­ca­tion and team­based care. The goal is to pro­duce more than $33.5 mil­lion in sav­ings for Medi­care and Med­i­caid ben­e­fi­cia­ries with lym­phoma or breast, colon, lung, pan­cre­atic, skin or thy­roid can­cer. McA­neny ex­pects to have 8,022 Medi­care pa­tients in the pro­gram plus 1,530 pa­tients cov­ered by Med­i­caid or com­mer­cial in­surance. She has pro­jected a 6.3% sav­ings per pa­tient, or $4,178 a year.

Car­di­ol­o­gists will also join the move­ment to med­i­cal-home prac­tices, the Amer­i­can Col­lege of Car­di­ol­ogy’s May pre­dicted. The med­i­cal home “fits hand in glove” with ac­count­able care or­ga­ni­za­tions, he said. But he ex­pects that car­di­ol­o­gists’ par­tic­i­pa­tion in NCQA’s recog­ni­tion pro­gram will be “abysmal” as long as the group’s per­for­mance cri­te­ria fo­cus on care pro­cesses rather than out­comes. His own car­di­ol­ogy prac­tice in sub­ur­ban Dal­las al­ready uses med­i­cal home tech­niques, such as in­volv­ing pa­tients’ fam­ily mem­bers in their care man­age­ment.

Re­searchers are study­ing the qual­ity and cost ben­e­fits of spe­cial­ist-based med­i­cal homes, funded by the Pa­tient-Cen­tered Out­comes Re­search In­sti­tute. The NCQA is spear­head­ing a $2 mil­lion study eval­u­at­ing the per­for­mance of on­col­ogy med­i­cal homes in south­east Penn­syl­va­nia. In ad­di­tion, Denise Hynes, a Univer­sity of Illi­nois Chicago pro­fes­sor of pub­lic health is lead­ing a $2.1 mil­lion study eval­u­at­ing a med­i­cal home for end-stage re­nal dis­ease pa­tients served by the U-I Hos­pi­tal and Health Sciences Sys­tem dial­y­sis cen­ter and Fre­se­nius Med­i­cal Care.

Also, a new recog­ni­tion pro­gram is com­pet­ing with the NCQA for spe­cialty-based med­i­cal homes. The Wash­ing­ton­based Com­mu­nity On­col­ogy Al­liance is work­ing with the Amer­i­can Col­lege of Sur­geons’ Com­mis­sion on Can­cer to de­velop stan­dards and per­for­mance mea­sures for on­col­ogy-based med­i­cal homes. The ef­fort is be­ing pi­loted at 10 on­col­ogy prac­tices—in­clud­ing the seven par­tic­i­pat­ing in McA­neny’s in­no­va­tion project. The goal is for the ACS com­mis­sion to be­gin ac­cred­it­ing on­col­ogy med­i­cal homes in 2016.

McA­neny said much de­pends on more in­sur­ers pay­ing spe­cial­ist prac­tices for the ex­tra ser­vices med­i­cal homes of­fer pa­tients, prefer­ably through a per-mem­ber, per-month fee. For ex­am­ple, at her prac­tice, when pa­tients tele­phone, a live op­er­a­tor al­ways an­swers. “Pa­tients who are sick and scared talk to a hu­man im­me­di­ately,” she said. “That is not some­thing you can bill for in the cur­rent fee-for-ser­vice sys­tem.” Plus, the open sched­ul­ing sys­tem and keep­ing the cen­ter open late and on week­ends mean higher staffing costs.

“Most (in­surance) med­i­cal direc­tors get it loud and clear,” she said. “But their con­tract­ing arms don’t al­ways un­der­stand that keep­ing pa­tients out of the hos­pi­tal is in their best in­ter­ests.”

Spe­cial­ist-based med­i­cal home prac­tices in the U.S.

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