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Can a specialty practice be a patient-centered medical home?

A column about keeping your practice in good health

By Victoria Stagg Elliott is a longtime staff member. She covered practice management issues and wrote the "Practice Management" column from 2009 to 2013. She also covered public health and science from 2000 to 2009. Posted April 9, 2012.

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Should cardiologists, oncologists, endocrinologists and other specialists providing care for long-term chronic conditions have patient-centered medical homes?

Should they say “yes” when a primary care practice asks, “Won’t you be my neighbor?” and invites them to be part of a medical home neighborhood?

The patient-centered medical home is viewed as a possible strategy for improving patient outcomes and reducing health care spending. Ongoing health system reform means there may be additional payment for specialty practices to participate in some way in this model, although not always.

Those working on the patient-centered medical home concept say specialty practices need to consider several issues before moving forward. Some may find that becoming a full-fledged medical home suits them if they provide most services, including a modicum of primary care, to a significant percentage of their patient population. Others may find it better to be part of the medical home neighborhood with closer links to a primary care practice serving as the center.

“Practices need to focus on their strengths,” said Tricia Barrett, vice president of product development at the National Committee for Quality Assurance. “Becoming a patient-centered medical home can be a pretty big shift for a practice.”

The NCQA provides medical home recognition to nearly 4,000 practices, although few are in specialties. The recognized specialty practices include one oncology practice and a handful of HIV/AIDS clinics.

“There may be a subset of patients who really do end up being fully managed in the speciality setting, but these situations are limited,” Barrett said.

The NCQA is developing a medical home recognition program due out within a year that is designed for speciality practices based on the neighborhood concept. Being a medical home neighbor requires speciality practices to coordinate care and follow up, much like the full model.

They would not, however, have to provide the primary care or prevention outside their purview. Rather, specialty practices would be closely linked to primary care practices that would provide prevention and other related services and act as the medical home.

“We’re focusing on what aspects of the medical home make sense for specialty practices,” Barrett said.

Deciding on a home

Medical home experts say the most important issue when specialties decide how or if to participate as a medical home or neighbor to one is the type of practice the speciality has and its patient population. Some patients access specialties more than a primary care practice, depending on the illness.

Specialty practices can act as the primary care source for some of their patients, according to a survey of 372 single-speciality cardiology, pulmonology and endocrinology practices in the April 21, 2010, issue of The New England Journal of Medicine. The survey found that 84.6% of specialty practices served as the source of primary care for 10% or fewer of their patients. An additional 13.7% were the primary care source for 10% to 50% of patients, and 1.7% for more than 50% of patients.

Other specialities expressing interest in the medical home model include cardiology, nephrology and psychiatry. Medical societies are advocating that the model may be appropriate for some practices.

“I really think that any area of medicine where the predominant disease process takes a vast majority of care could be the center of [care],” said William A. Zoghbi, MD, president of the American College of Cardiology.

Practices need to consider their culture and the personality of physicians when setting up a medical home or neighbor model.

“If you are not the kind of physician who likes to work in a group, ask yourself if this care model is really your cup of tea,” said Mark Golberg, managing director of the health care provider/accountable care organization practice at Recombinant Data Corp. in Newton, Mass.

Practices also need to consider what kind of technology and personnel will be needed to coordinate care and provide patients with increased access.

“The biggest barrier is obtaining the information that you need as timely as possible,” Golberg said.

Medical home experts say practices need to consider what financial support is available locally. Some insurers provide additional payments to speciality practices for medical home services. Practices also need to assess how becoming a patient-centered medical home will work with any accountable care organization they might take part in.

Victoria Stagg Elliott is a longtime staff member. She covered practice management issues and wrote the "Practice Management" column from 2009 to 2013. She also covered public health and science from 2000 to 2009.

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