As implementation of health reform gains momentum, subspecialist physicians are concerned about their lack of a role in care coordination and the patient-centered medical home model.
Endocrinologists, for example, face challenges in qualifying as the medical home. The average endocrinologist spends about 50%-60% of his or her time treating and managing diabetes patients, and the remaining time consulting on other conditions, according to Dr. R. Mack Harrell, an endocrinologist in Fort Lauderdale, Fla., and a member of the board of directors of the American Association of Clinical Endocrinologists.
The AACE and the American College of Rheumatology are among a handful of medical specialty societies that have not signed on to the concept of the patient-centered medical home. “We're a little bit frustrated about where we fit in,” added Dr. Karen Kolba, a rheumatologist in solo practice in Santa Maria, Calif., and chair of the ACR's Committee on Rheumatologic Care.
It's not that ACR members don't support increased access for patients or coordinated care; rather, Dr. Kolba said, they feel they have been excluded from the model.
In 2007, the American Academy of Family Physicians, the American Academy of Pediatrics, the American College of Physicians, and the American Osteopathic Association issued a paper outlining the principles of the patient-centered medical home, which seeks to provide comprehensive primary care to children and adults.
Under the model, each patient has a personal physician who directs a practicebased care team and is responsible for providing all of the patient's health care needs or coordinating that care with another provider. The model also emphasizes evidence-based medicine and clinical decision support, enhanced access for patients, and additional payment for the personal physician for providing care coordination and improving quality.
A voluntary recognition program created by the National Committee for Quality Assurance (NCQA) aims to operationalize the model; physicians who meet the program's standards can qualify for additional payment from certain health plans. The standards measure a practice on access and communication, patient tracking and registry functions, care management, referral tracking, and electronic prescribing, among others.
Although the medical home model doesn't specify that only a primary care physician can qualify, the criteria make it nearly impossible for specialists to act as a medical home, Dr. Kolba said. For example, rheumatologists frequently are the main point of medical contact for patients with chronic rheumatologic diseases and they provide a significant amount of coordination of care, she said. However, few perform or coordinate nonrheumatologic care such as a patient's regular mammogram. And that's a sticking point in being able to qualify as a personal physician under the medical home, she said.
Dr. Kolba said she supports increasing payment for primary care, but not at the expense of other physicians. And she said primary care physicians ought to be entitled to additional pay for the work they do, without creating a new system to justify the increases.
“It's hard to see how you could completely give up your consulting role so you could fit into a medical home–type model for half your practice,” added Dr. Harrell.
The AACE is working to get endocrinologists, and all physicians, paid for those administrative burdens that take up so much time. The organization is currently working to generate a new CPT code for preauthorizations. “We're looking for other avenues to get paid for what we do,” he said.
As tests continue on the value of the medical home, Dr. Harrell said the key will be to ensure that primary care physicians and specialists find better ways to communicate with one another. But he anticipates that communication will be an ongoing challenge, especially since Medicare is no longer paying specialists more to perform consultations. “None of the codes, as they are presently written, are specifically constructed to pay for communication between physicians, which could potentially exacerbate an already difficult situation,” he said.
AAFP leaders defend the medical home model and specialists' role in it. The patient-centered medical home was very purposefully defined to include a “personal physician”—not a primary care physician, said Dr. Terry McGeeney, president and CEO of TransforMED, a subsidiary of the AAFP that helps primary care practices transition to the medical home model.
Although most practices using the medical home model will be led by primary care physicians, not all will be. The personal physician could be an infectious disease specialist, a neurologist, or an oncologist, he said.
But the key, Dr. McGeeney said, is that the physician must provide a medical home for the whole patient, and not focus on a certain disease or organ system. That means that a neurologist, for example, must keep track not only of the neurologic care, but also the patient's cholesterol levels and mammogram results. They don't have to perform these services themselves, but they have to coordinate and track them, he said. In the medical home, the personal physician is the “quarterback” for the patient's care and there's no “free pass” on those responsibilities for specialists, he said.