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New health care delivery systems proposed
The Affordable Care Act (ACA) established a new service called the Patient-Centered Medical Home service. It is a description of patient advocacy which may over time change the way much of health care is delivered. There is already a program model being set up in Pennsylvania so it is possible, if successful for it to spread. If implemented it will change the way we interact with almost all doctors. Here is description of what might be.
To explain the concept the Federal Government authored a small paper that was used to explain this section of the law ("Joint Principles of the Patient-Centered Medical Home," 2007). The article explained that the concept of the Patient-Centered Medical Home. In essence the idea is to funnel almost patients through a Primary Care Physician (PCP) before seeing a specialist. I do not know about most people who will read this small bit of writing, but I personally have largely bypassed my PCP and am making appointments directly with the specialists. In my case I see cardiologists, neurologists, endocrinologists, rheumatologists and various sundry other specialists as needed. In essence I manage my own care.
Under the new system the PCP would become the health care traffic cop. You need a rheumatologist, you first see your PCP and if they believe it is appropriate you are referred to the specialist. Understand once at the specialist, they would either continue care or treat and send you back to your PCP. The idea is not to force a patient to a PCP prior to ever specialist visit. By the same token, it is likely that PCP’s may do things like routine A1C’s, office visits, prescription refills etc. One outgrowth might be instead of seeing ones endocrinologist four or five times a year, one might see them once or twice a year, filling in the routine visits with the PCP.
The number one change is that must occur before such a model could be put in place is that most PCP offices have to be upgraded. This is where the Patient-Centered Medical Home portion of the act comes into play. One needs to think of the act as a practical way to bridge the gap from where most PCP offices operate today to where they would have to become to be trusted partners of specialists. The ACA is designed to help this transition by establishing a medical extension program to introduce best practices to most PCP offices. This service would be set up like the agriculture extension office model ("Joint Principles of the Patient-Centered Medical Home," 2007). To make it clear the ACA is not attempting to force this routine. Instead, the ACA, if fully funded, would set up this extension format to improve patient care at the PCP offices.
Why might this work? Well to understand it one must first know that there are approximately 353,000 separate PCP practices in the country ("PA Spread: PA spreading primary care enhanced delivery infrastructure," 2013). “Nearly one-third of practices are still solo or 2-physician practices, many serving small communities” (Phillips et al., 2013, p. 175). The belief is that these office generally will be more open to technical assistance, co-operative purchasing, implementation of best practices and shared services (Phillips et al., 2013). This obviously makes sense since many of these offices are more or less operating in a bare bones low profit situation. The concept being that these small offices will want to update care practices if for no other reason to remain or become more profitable.
Will this revolutionize care? It remains to be seen. But at this time Blue Cross / Blue Shield of PA has begun to reimburse doctors who use these services at a higher rate than those who do not avail themselves of the services. That is a powerful incentive to participate. I believe most advocates understand that in order to be effective PCP’s need more and faster reimbursement of claims. At least in PA this might be occurring. If it does happen these rural doctor practices may become better equipped to deal with patients in place in their hometowns instead of at large medical centers which require travel.
Will it be good or bad for patients? It is hard to tell. In some respects it will be good, effectively lowering the cost of delivery of services and reducing duplicate services. For instance I spoke to my endocrinologist just last week about a refill for simvastatin I will also speak to my cardiologist about it this week. At the end of this week I will have had two conversations about a refill of a prescription, both taking a specialist time, when in fact the PCP is fully capable of filling the script. Obviously specialists are far more expensive. On the other hand, both doctors have a stake in using simvastatin thus they correspond on the matter. The endocrinologist sent a note to the cardiologist assuring her that he supported prescribing of the drug. By the same token if a PCP did this job they would need to consult with both as well however, it would likely be in batch as opposed to individual communication. So saving money? Well maybe we shall see.
Joint Principles of the Patient-Centered Medical Home. (2007). Retrieved February 2, 2014, from http://www.pcpcc.net
PA Spread: PA spreading primary care enhanced delivery infrastructure. (2013). Retrieved February 3, 2014, from http://paspread.com/
Phillips, Robert L., Kaufman, Arthur, Mold, James W., Grumbach, Kevin, Vetter-Smith, Molly, Berry, Anne, & Burke, Bridget Teevan. (2013). The Primary Care Extension Program: A Catalyst for Change. The Annals of Family Medicine, 11(2), 173-178. doi: 10.1370/afm.1495