A discussion of patient management shifts that will occur in Physician practices
Patient-Centered Medical Home (PCMH) has arrived full-force onto the American medical scene, and it is here to stay. You may not like it, you may love it, or you may already be a practitioner, but regardless of opinions and beliefs the payer industry will impose PCMH on all morbidity-care practices. It is a money ‘thing’…
In short, the underlying belief behind PCMH is ‘pre-emption’. Specifically, treating a patient before the onset of a disease (smoking cessation, weight loss), or before onset of progressive levels of complexity (diabetes, HBP), or episodic critical-care treatments (CHF, COPD). By pre-empting next-stage or episodic critical-care events, the patient is better served (quality of life), critical-care medical resources are conserved, and costs are contained. Perhaps it may be summed-up as an ounce of prevention is worth a pound of cure.
However, to accommodate PCMH, change is not on the horizen… it has arrived. Large or small, many Providers/ practices are under-prepared. The following are some initial ingredients that medical practices will need to address in the near future:
1. Patient Panel Size. Let’s be realistic - Providers/practices adore large panel sizes: the more, the better, as it provides an income source. Seek to shrink the panel and providers get agitated; however, losing money may be a greater agitation. Let’s use an example under PCMH (numbers are illustrative ONLY). If a Provider has a panel of 3600 patients, assume 1200 are low-maintenance and seen 1x annually. Assume 2400 are diabetic with co-morbidities and seen 3x annually. That equates to 8400 office visits per year. Now, assume a provider sees 32 patients per day, for 48 weeks per year, or 7680 exam slots. That will be a shortfall of 720 exams. Under PCMH and pre-emptive medical management, this shortfall will cost the provider/practice some income from payers. So, the provider must find ways to have the practice accommodate the shortfall – sharing patients, adding MDs/PAs, patient involvement or leveraging technology!
2. Patient Involvement. Patients must have greater involvement (and responsibility) for their healthcare. Technology offers tremendous benefits in areas like diabetic monitoring, BP monitoring, or for any measurement that can be obtained remotely. Large payers, as well as The Robert Wood Johnson foundation have funded large-scale initiatives in this area. Payers are actively encouraging Providers to engage their patients in their own morbidity measurements.
3. Tele-Medicine. It is interesting that Tele-Medicine has emerged as strongly as it has. In some ways it represents a reversion to earlier periods of medicine when MDs made house calls (or flew aircraft like the Australian bush doctors); now it can be accomplished electronically. The advantages are clear – nurses may treat patients locally and consult with MDs far away; patients can schedule 5 minute Skype sessions with their PCP to review morbidity measurements, and so forth. These are practices already implemented in regions like Singapore; soon they will be part of the American medical landscape.
4. Dropping Patients from Panel. At some point, a provider/practice will be financially penalized because of patient non-adherence to protocol. The decision is then whether to retain those patients that cause financial harm, or remove them from the practice panel. No provider/practice will have 100% patient adherence, but when the financial pendulum imperils financial solvency, then some segment of the panel will need to be triaged off the panel.
Carl C. Jaekel, MS, CPHIMS, ACHE
Strategic Advisory Services
Santa Rosa Consulting