Medical Homeless: Ophthalmology and the PCMH

The patient-centered medical home is evolving, but specialists are still looking for their place.

By Joseph Burns

Seeking to foster better coordination of medical care, third-party payers, including Medicare, have been enrolling patients in patient-centered medical homes (PCMHs). Since the first PCMH opened in 2002, proponents, such as the Patient Centered Primary Care Collaborative (PCPCC), say that PCMHs have improved quality, lowered costs and increased efficiency.

Yet, as ophthalmologists and other specialists know, the PCMH is imperfect, primarily because primary-care physicians have less than ideal relationships with specialists, and the PCMHs replicate this flaw.

Addressing this shortcoming, several organizations are promoting the evolution of PCMHs to the patient-centered medical neighborhood (PCMN). In January, 15 health systems and provider organizations said they would participate in a three-year PCMN demonstration project.

Under a $20.75 million grant from the Center for Medicare and Medicaid Innovation, the PCMN project will serve 157,000 Medicaid and Medicare beneficiaries nationwide, according to an announcement by TransforMED, an affiliate of the American Academy of Family Physicians, and others. The PCMN is designed to improve and strengthen collaborative relationships among primary-care practices and hospitals and specialists.

NCQA To Recognize Specialist’s Role

Another organization promoting this evolution is the National Committee for Quality Assurance (NCQA), which certifies medical homes and is planning in March to recognize specialists as participating in PCMHs, says Johann Chanin, RN, MSN, NCQA’s director of product development. NCQA has recognized 5,198 PCMH practices.

“To make the medical home work, one of the requirements is having good coordination between primary-care physicians and specialty practices,” Ms. Chanin says. “But PCPs (primary-care physicians) complain that they can’t make specialists send them the information they need after the specialist has seen a referred patient.”

In its research, NCQA found that PCPs and endocrinologists who see patients with diabetes often complained about not getting what they needed from ophthalmologists, Ms. Chanin says. “When the PCPs said they didn’t get reports back from the ophthalmologists, that led us to ask, What are the specialists paid for? Are they paid to do these exams or to send a report to primary care? It could be that they felt they were paid to do the exam but not send a report back. I believe that is the crux of the problem and yet the report is critical for PCPs treating diabetes patients.”

A PCP recognized under NCQA’s Diabetes Recognition Program can earn an incentive bonus of as much as $100 from health plans for each diabetes patient the physician sees. But to earn this incentive payment, PCPs have to meet certain criteria, one of which is an annual eye exam for retinopathy for diabetes patients. If the PCP has no record that a patient had an eye exam, the PCP could lose the incentive payment, Ms. Chanin explains.

Incentives at Risk

Both PCPs and specialists are at fault for such failings, she adds. “Communication on both sides is not good,” Ms. Chanin says. “Specialists don’t deliver consult reports in a timely manner, but PCPs don’t give the specialists what they need to do effective consults.”

In March, NCQA’s standards for specialty care will require specialists and PCPs to have agreements, either formal or informal, that spell out what each party needs from the other. Not all referral relationships will require such an agreement, but specialists who receive many referrals from a PCP may benefit from one.

Terry McGeeney, MD, MBA, TransforMED president and CEO, agrees that such letters of agreement will improve referral relationships. “We’re asking medical home practices to identify the specialist and subspecialist practices they will refer patients to and use letters of understanding to outline what the PCP will do, such as request the appropriate screening and send all needed documents to the specialist,” Dr. McGeeney says. “In return, the specialist promises to send timely information back to the practice within 48 to 72 hours.”

Ideally, the PCP will send that information electronically. Such an agreement also would state that if a patient needs a referral to another specialist, the specialist will check with the PCP first. If the patient needs imaging, then the specialist checks with the PCP to make sure it hasn’t been done already.

At Intermountain Healthcare, PCPs Manage Medical Home Referrals

At Intermountain Healthcare in Utah, the primary-care physicians manage referrals in patient-centered medical homes (PCMHs). An integrated delivery system, Intermountain has run PCMHs since 2004, says Mark Briesacher, MD, senior administrative medical director for the 900-member Intermountain Medical Group. As in most medical homes, a PCP is responsible for collecting data in each patient’s care. Dr. Briesacher offers an example of a patient with diabetes. “We provide a list of every diabetic patient a PCP has. Then, we ask the physicians to track five important measures for each patient,” he says. “One of those measures is whether the patient has had an eye exam in the past year. But if the patient’s diabetes is well controlled and their eyes are healthy, they may not need an exam every year and so we are changing that measurement to every two years.” Allyson Servoss, MD, visits with a patient at Intermountain Healthcare’s Salt Lake Clinic. Courtesy: Intermountain Healthcare However, most of the ophthalmologists and optometrists in the plan are not connected to Intermountain’s electronic record system. “So, we sent them all a letter encouraging them to send us copies of their notes when they’ve seen our patients to ensure that the communication is flowing back and forth,” he says. The specialists bill the patient’s insurer. There is no payment from the PCMH to the specialists. Intermountain is developing a similar process to help ophthalmologists and optometrists track patients with AMD and glaucoma and who have not had annual eye exams. Once the process is standardized, Intermountain will expand the project to support PCPs and affiliated eye-care professionals. Dr. Briesacher expects ophthalmologists to send notes back to the PCPs. “Even though we are using simple tools to manage care, these clinical notes are nonetheless important for glaucoma patients,” Dr. Briesacher says. “But we need the additional data to provide decision support to our teams so that they can follow up on patients who have not had annual exams and re-engage them in this important part of their care. If we didn’t track care in this way and no one followed up for two or three years, the patient could go blind in the affected eye.”

“In a medical home, the PCP also agrees to coordinate all medication refills,” Dr. McGeeney says. “That part of patient management is a pain for specialists, especially for ophthalmologists. Having someone managing patients’ medications is important to minimize the chances of an adverse event from a drug-drug interaction, for example.”

Good Communication Required

William L. Rich III, MD, FACS, the medical director of health policy for the American Academy of Ophthalmology, is not sure that a formal or informal agreement between the PCP and a specialist will solve the problems both parties experience. But one outcome is certain, he says: If ophthalmologists do not send consult letters back to referring physicians quickly, they will stop getting referrals.

“The ophthalmologist might not even know a patient is in a medical home. But you still have to write a letter to the PCP to explain all the issues you’ve found when examining the patient,” he says. “If I don’t, that PCP is not going to refer patients to me. If they’re doing their job properly, ophthalmologists will get a lot of referrals regardless of whether the patient is in a medical home or not.”

But the PCMH itself does not pay ophthalmologists or other specialists directly, Dr. Rich adds. “There is not enough payment going to those doctors in PCMHs to pay for specialists’ consults,” he says. Medical homes pay PCPs in a variety of ways, usually a combination of fee-for-service and a per-member-per-month (PMPM) rate. If a PCMH patient needs specialty care, the patient’s insurer pays ophthalmologists and other specialists as needed.

“I do not know of a medical home that pays a share of the management fee for specialty care,” Dr. Rich says. “All that money stays in the medical home. Anything extra goes for the expanded management services the medical home provides.”

Ophthalmologists who see patients referred from a PCMH simply need to keep patients and referring physicians happy, which almost always means providing timely and high-quality care, and communicating well with the patient and the referring doctor, he adds.

Written Referral Agreements Are Rare

Although NCQA, the American College of Physicians (ACP) and other organizations recommend using formal agreements for referral arrangements, such agreements are rare, Dr. Rich says.

In a competitive market such as Boston or Washington, D.C., ophthalmologists will want to get as many referrals as possible from PCMHs because these patients are likely to be insured. “For those patients, you don’t mind doing whatever extra communication you have to do,” Dr. Rich says. “But suppose you’re in a small town in the Midwest where you’re overwhelmed with patients. You might not want to work with physicians in a PCMH unless you’ll get paid some part of the management fee in addition to getting the insurance payment.”

Yul D. Ejnes, MD, MACP, the immediate past chair of ACP’s board of regents and a practicing internist with Coastal Medical Group, a PCMH in Cranston, R.I., says the best referral arrangements work because both parties understand the others’ needs. Two years ago, ACP issued a position paper that stated the PCMH/N could improve care integration and coordination within medical homes.

The challenge is to compensate specialists for their role in reducing overall costs. “The ophthalmologists and optometrists we work with in our practice automatically send reports when they see our patients,” Dr. Ejnes says. “They don’t get paid anything extra but perhaps they should because of the extra work they put in for our patients.”

PCPs can call specialists or subspecialists for what Dr. Ejnes calls a “curbside consult” and then decide to treat the patient without a referral. “Those specialists should be compensated for their expertise in helping to control overuse and needless spending,” he says.

Another example involves the radiologist who works with PCPs to reduce the number of imaging scans. “Now, if fewer scans are prescribed, how do we address the decline in radiologists’ income?” Dr. Ejnes asks.

“When a specialty or subspecialty practice participates as a medical home neighbor, it should be paid a percentage of the monthly PMPM rate or perhaps a financial adjustment could be added as an incentive for quality work or for curbside consults,” Dr. Ejnes says. “That extra effort should be recognized. If a cardiologist and a PCP work together to reduce hospitalizations, they could share in any savings that result. If there are some savings then there should be some bonuses too.” OM