It Takes More Than a Team

“It takes more than a team to do what, Curmudge?”

“To establish a medical home, Jaded Julie. It also requires an angel.”

“Angels? Aren’t those dead people with wings?”

“No, Julie. In this case angels are live people—or organizations—with money. It’s a term used in the theater to describe people who finance a new production.”

“I must admit, Curmudge, that I was puzzled at the idea of a solo-practice doc, who has to see more and more patients to keep his head above water, hiring lots more people, proclaiming his shop to be a medical home, and suddenly becoming financially viable. There must be a ton of transitional expenses; I guess they are paid by the ‘angel.’ So why should an organization support a practice’s transition to a medical home?”

“An insurance company might be a good example. They would anticipate that the medical home would take better care of their members (policy holders) so they would have fewer specialists, duplicate tests, and ED visits to pay for. Their support could be in the form of capitation, i.e., dollars per member per month. Another example would be a large health care organization that envisions the medical home to be the wave of the future in primary care.”

“Let’s assume that the medical home has recruited their team, purchased their information technology, and trained everyone as we have discussed in recent weeks. What must they do to put the operation in the black?”

“My one-word answer, Julie, is ‘efficiency.’”

“Wow! That’s the first time ever that your one-word answer was not ‘Lean.’ Of course we already know that the team members gain much of their efficiency by using Lean principles and tools. Can we look at some of the ways that the medical home improves their efficiency?”

“Let’s start with an intuitive, uncomplicated look at physician compensation (of course, there isn’t such a thing). Mid-level providers will handle routine patient care; this will enable the physician to provide higher-intensity services, as measured by relative value units (RVUs). Electronic technology will reduce the physician’s non-value-added time with each patient; he/she will not have to shuffle through chart pages, can use the decision-support tool to confirm his diagnosis and treatment plan, and can generate notes for the encounter in real time. These attributes of the medical home should permit the physician to see more patients and perform more services per day. This will enable him to increase his compensation, or alternatively, maintain his compensation while working fewer hours.”

“I assume, Curmudge, that someone has investigated the financial side of the medical home more rigorously.”

“It was studied by Spann and a long list of coworkers in 2004 (1). We won’t discuss the assumptions used in their model; the list would stretch from here to Darboy. Here are some of the features of a medical home (they called it the ‘New Model’) that they studied and the outcomes predicted by their model (not all are intuitive):

Open-access scheduling (some same-day appointments)—Fewer visits per patient, but higher RVUs for services provided.

Electronic health records—Overall increase in efficiency (after training) including more accurate billing.

Online e-visits—Presently no reimbursement. If implemented, it would be at a lower level than an office visit.

Team approach (leveraging clinical staff)—The physician can serve a larger panel of patients by using clinical staff to perform routine tasks.

Clinical practice guidelines software—Allows physicians to rely more effectively on a team approach to medicine.”

“I trust you read the more recent paper by Rosenthal (2).”

“I did. He said that reimbursement policies will require reformulation in order to institutionalize the medical home, and he reported on reimbursement models recommended by several physicians’ associations. They included:

· A fee for service, including e-visits.

· A per-member per-month management fee.

· A quality incentive that recognizes achievement of standards of care.”

“Curmudge, from the financial standpoint it appears that the team approach to medicine and the use of electronic technology are going to be the big winners for the clinic. Of course, one of your ‘angels’ will be needed to help them get through the expenses of transition. You must be pleased at the essential role played by teamwork and empowerment.”

“I certainly am, Julie. The medical home should be a viable way to practice primary care if it is implemented efficiently by committed leadership and involved staff.”

“Involved? Committed? I thought those two words meant almost the same thing.”

“Not when you consider eggs and bacon, Julie. The hen was involved, but the pig was committed (3).”

Affinity’s Kaizen Curmudgeon

(1) Spann, S.J. et al. Report on Financing the New Model of Family Medicine.
http://www.annfammed.org/cgi/content/full/2/suppl_3/s1
(2) Rosenthal, T.C. The Medical Home: Growing Evidence to Support a New Approach to Primary Care. (Sept. 2008) http://www.jabfm.org/cgi/reprint/21/5/427
(3) Hunter, J.C. The Servant, p. 120 (Crown Business, 1998)