21st National Conference – Reports from Thursday Breakout Sessions – April 15, 2010

The 21st National Conference on Primary Health Care Access met in six breakout sessions on Monday, April 12, 2010. The following question was posed to each of six teams:

The concept of the “medical home” is emerging as an increasingly sophisticated idea, that indeed may promote primary health care access for many of the nation’s most vulnerable persons. What do you see as the promises and the challenges of the medical home as a mechanism for increasing primary health care access?

Team 1. L. Burnett (Lead), Babitz, Fernandez, Hansen, Maudlin, Troy

Family medicine revisited:

  • it decreases access
  • it decreases reimbursements
  • it is hard to meet performance goals unless “cherry picking” [atoemts
  • creates “perverse” incentives

Medical home is “designed” to clarify the true role of primary care. It is not defined as care of the “family” – only the patient. It creates a system in which any specialist can be a “medical home”.

Community health centers are currently the most effective comprehensive care for underserved communities.

Medical home is stated as an effort to save money, but is based on poor data.

NCQA medical home tiers of certification

Repacking of “gatekeeper” in a more politically correct manner.

CHCs/FMRP Centers. These work most effectively. CHCs will increase in political power as two-tier system becomes legislatively entrenched.

L. Burnett, scribe.

Team 2 W. Burnett (Lead). Baird, Flinders, Hara, North, Vega

The medical home is an evolving concept that many don’t understand.

Kaiser has had the Medical Home for decades, especially now with Kaiser’s electronic health record.

NCQA payments drive the Medical Home.

The medical home can take more effort. For visits, you need a team to help make care efficient (i.e., an MA gives immunizations prior to an order).

Kaiser has population disease management systems which manage chronic illness remotely, without a physician being present. It has proven to be cost-effective.

Some payers want visit-based care and are closed to new models, such as using e-mail to address patient concerns.

The medical home works well in capitated systems. It’s more complex to implement in low-income communities.

Access isn’t a natural outcome of Medical Home. Access needs to be addressed proactively.

Medical homes have received bipartisan support, and we’ll need to take advantage of that.

Team 3 Wilke (Lead), Bejinez-Eastman, Fort, Hines, Osborn, Webster

Promises:

  • transparency, portability of information
  • efficiency in record-keeping
  • relationship builds over time
  • quality as an group, individual measure
  • team approach, with members having an equal vision
  • better quality level for all rather than have a few motivated patient
  • relationship of patients to patients and providers to providers

Challenges:

  • obtaining reimbursement for time spent by all
  • obtaining buy-in of all players as Medical Home “members”
  • the financial risk for providing a Medical Home
  • obtaining equal access for all
  • applying a small paradigm of care to a larger group of people
  • minimum standards for all vs maximum standards for a few
  • system development for task completion
  • home members training on how to live in “home”
  • receptive approach to patients to have interns in the “home”
  • control of staff behavior

Team 4 Herman (Lead), Casey, Fowkes, Kasovac, Palafox

  • payment reform has to support the medical home
  • medical home means changing the way you practice
  • team home visits an important part of access

Fowkes, scribe.

Team 5 Ross (Lead), Coleman, Freeman, Kimball, Peck

  • Will likely not improve access unless system changed, but will improve systems of care for those already “in”.
  • May reduce pressure on physicians and PCP by downloading less complex care to other members of the team in the home, thereby freeing time to increase patient numbers cared for in the home.
  • It may open up other access points for care such as phone and/or computer/e-mail access, but the poor rarely have the access to technology nor the knowledge/sophistication to use this form of access.
  • May be able to take the care to the patients home by using mobile clinics and other innovations
  • We will need to improve social responsibility to improve access and care-Josh says: “We don’t care for or about each other in the United States”

Ross, scribe.

Team 6 Clover (Lead), Erickson, Frey, Lee, Pugno

  • The fact that Family Medicine (FM) has taken a lead in the Primary Care Medical Home (PCMH) has been lost to the rest of the world
  • Major strength of PCMH: it is so well-designed that people like it however they conceive it
  • the challenge today: the force out there in the workplace not sufficient enough to deliver
  • misconception that PCMH allows for less FM docs for more pateints
  • not a more efficient healthcare system
  • dilemma: we may have created a false misperception with the public that we are not able to fulfill
  • reimbursement will need to support a change in practice to make this successful
  • other specialties have taken up the PCMH to gain the reimbursement associated with it
  • many family physicians feel that they are being asked to do more and more without compensation
  • medical students are expecting this – but do we have a model of PCMH?
  • increased enrollment medical students, but decreased FM residency positions
  • need fo increased general Internal Medicine docs as well, but they are dying out
  • AAPA has been great partner with AAFP, but there is no national nurse practitioner group. Whom do we talk to? How do we get good data?
  • AARP in favor of PCMH, but has not been visible with this
  • but, we cannot raise public expectations that we cannot deliver
  • payment levels and bureaucratic rules will determine how successful PCMH will be
  • How to model PCMH in a Family Medicine Center (FMC), when FMC is not able to make the dollars required to run it
  • PCMH model will deliver primary care [in communities where] Emergency Rooms and “docs in a box” also deliver primary care
  • Need an enlightened team; PCMH requires abstract thinking, and physicians typically are linear thinkers