Patient Centered Medical Homes: One doc's view from the trenches

According to pediatrician Xavier Sevilla, who spoke last Friday at the National Committee for Quality Assurance's policy conference in Washington, D.C., the patient/family centered medical home is not a destination, but rather, a journey. "We need to completely transform how we deliver care to bridge the chasm between where we are and the patient/family centered medical home," said Sevilla, who works for Whole Child Pediatrics, a 3,400-patient practice and fully-functioning PCMH based in Lakewood Ranch, Fla.

That journey, toward a more patient- and family-centered model of care, involves several paradigm shifts, said Sevilla. The focus must shift from caring for the individuals to population-based care. For Sevilla, that means keeping all patients as healthy as possible, not just those who show up any given day. His team knows which 251 patients have asthma and proactively checks up on them, sending reminders to get them into the office for check ups.

Another shift is from physician to team-based care. Sevilla's office consists of two pediatricians, two nurses and 2.5 clerical staff. Besides daily huddles and regular practice meetings, nurses do outreach, recall and follow up. A dedicated care coordinator works with high-risk patients--those with special needs or chronic conditions.

Because patients really prefer a continuous relationship with their physician--not just 15-minute visits--Sevilla's practice is moving from episodic care to continuous care. Every day, each practice team contacts or communicates with about 100 patients. Perhaps 10 complex patients will get face-to-face visits. The doctor may manage 20 to 30 patients' problems via email, telephone or group visits. Other team members will help care for the remaining 60 to 70 patients. Nurses counsel patients on lifestyle modifications and medications, and follow up on acute conditions.

Although healthcare traditionally has been organized around face-to-face visits, Sevilla noted that a practice can do a lot with less face time. But then there's that pesky payment problem.

The current payment system encourages quantity over quality, and rewards procedures over evaluation and management. Sevilla noted that he could get more money from Medicare for freezing one wart off in five minutes vs. trying to prevent a child with an acute asthma attack from going to the ER, which could take 25 to 40 minutes ($100.20 for the asthma management vs. $102.51 for the wart).

The current payment system does not support the medical home because payments are made only for services administered by clinicians, not other team members. And it only covers services performed in the office during face time. As a result, all of the work performed by follow-up and outreach staff outside of office visits is not covered.

The ideal payment system would support population-based care, team-based care and continuous care. It would incentivize care coordination instead of ignoring it. Sevilla also noted that in primary-care offices, cash flow is a big problem when you're not paid for 30, 60, or 90 days. He would prefer to get monthly payments per member, per month, plus additional pay-for-performance payments that can be shared with all team members.

"I don't like the status quo," said Sevilla. "Let's rewrite the script."

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