Suggs job also requires diplomatic skills in dealing with other specialists. King says about 10% to 15% of Prime Cares patients live in Mississippi or get prescriptions filled across the border, and this can sometimes cause some bumps in the patients treatment. But Suggs says physician attitudes toward privacy regulations under the Health Insurance Portability and Accountability Act of 1996, not the law itself, lead to these problems.
Some specialists wont send their reports back to useven if we referred our patients to them, Suggs says. It has nothing to do with state lines; its the individual doctors interpretation of HIPAA.
Other times, its not their attitude about HIPAA but their attitude in general that causes problems. Some specialists say they dont want the primary-care physicians notes, Suggs says. They say, No thank you; its a waste of our fax paper.
Linder says that this attitude is still common and ends up costing the healthcare system money. There are times he will have test results sent to specialists, he says, and then discover the specialists ordered the same tests anyway.
People have to be dragged kicking and screaming to work together, Linder says.
Theres also some wariness of the medical-home concept among specialists, because of the fear that if primary care gets more money, specialists will get less.
Everyone realizes the pie cant get much larger, King says, noting how the nation spends about 16% of its gross domestic product on healthcare, a $2.3 trillion healthcare bill. If we pay primary care more, it will have to come from somewhere. We see the money coming (from) savings from having fewer hospitalizations and emergency room visits, and, as EHRs get tied together, duplication of services will be less.
Both King and Patric say that the primary-care reimbursement for medical-home services shouldnt result in less compensation for specialists, but both add thatif medical homes work as well in practice as they do in theoryimproved healthcare outcomes will lower the demand for specialists while increasing demand for primary-care physicians, and a balance will be achieved that results in fewer specialists being paid about the same rate they are making now.
If people are healthier and dont need as many procedures, then there will be less need for specialists, Patric says.
Patric adds that its just not a matter of the healthcare industry waiting for insurance companies to flip a switch and reimburse for care coordination and other medical-home services.
When a physician sees a patient with a Blue Cross card, they think its monolithic and that everyone has the same coverage, Patric explains. We administer some 300 different plans, usually for large companies, and those companies decide what the benefits will be.
Patric says he knows of one large company that has been promoting the medical-home concept, but its support coincides with a desire to abandon its disease-management program.
In June, the industry group Americas Health Insurance Plans issued a set of principles for patient-centered medical homes that included the use of pilot testing before moving forward with reformed payment models, linking payment to measurable improvements, and using health IT to facilitate evidence-based integrated care. A written statement released by the AHIP board calls the medical home a promising concept that would replace episodic care with a sustained relationship between patient and physician.
The AHIP board adds that payment should reflect the level of management required for the population served, and should also encourage measurable improvements in clinical quality, access and satisfaction.
Though care coordination is a large part of the concept, King says theres more to achieving NCQA medical-home designation than just that. Enhanced access is a major component and, to achieve that end, Prime Care instituted open-access scheduling two years ago. If you call today, you will be seen today, King says.
As a result of keeping about half his appointment slots open, King says he may show up for work with only 15 patients scheduled to visit but wind up seeing 35 before the day is through.
It fluctuates, but not terribly bad, King says. Also, this is an agricultural area. So, if its wet, farmers want to get in before its dry.
Although there are no convenient-care clinics operating inside Selmer retail businesses yet, King says he believes Prime Care had to compete with the concept, and says the idea behind open-access scheduling is to improve patient satisfaction and, so far at least, its having that effect. He admits, however, that part of the reason is because patient expectations have fallen so low. Theyre so used to being put off, King says.
Open access isnt unconditional, however. King says patients give up the right to choose the doctor they want to see and, instead, see the physician who has a schedule opening. They also give up their right to by the ways.
You cant come in for a sore throat and say, By the way, I need my cholesterol checked, he says.
Another component of the medical home is enhanced communication. Part of that is being addressed by Beverly Dickey, whoin describing her role at Prime Caresays Im the nurse who became the IT person.
In addition to preparing for testing to begin electronic prescribing, which will replace Prime Cares computerized fax method, Dickey is working on developing a Web site application that will provide patients with results of their laboratory tests over a secure e-mail. Patients would have access to the same secure e-mail system to send questions about those tests to nurses.
Among the taller stacks of paper neatly arranged on Dickeys desk is a work-in-progress project that, when finished, will serve as a guide to the other Prime Care doctors to make sure theyre implementing the medical-home components correctly.
Im putting a manual together on how this process works and to make sure the patient protocols are met, Dickey says. This includes the creation of population registries that help chart the progress of patients with diabetes, hypertension and other chronic conditions. Such written standards are part of the NCQAs requirements for a medical-home designation.