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Curbside Consult with Dr. Jayne 4/4/16

April 4, 2016 Dr. Jayne No Comments

I had lunch with some of my former colleagues the other day. One of the hot topics was the relatively new Patient-Centered Specialty Practice Recognition program from NCQA. Several of the specialty physicians who were at the table are employed by a health system and are being encouraged to participate in the program as part of an overall accountable care strategy.

The program is designed to recognize specialty practices that are committed to access, communication, and care coordination. Although it should be fairly easy to “encourage” employed physicians to participate as a condition of their employment, the physicians around the table were unconvinced that the independent specialists would be interested.

Our community has many more independent specialists than owned/employed, while the majority of primary care physicians are no longer independent. Several primary care physicians spoke up about the difficulty of trying to achieve Patient-Centered Medical Home recognition since they felt they were being asked to do more but were not allowed by their employers to add staff.

However, at least as primary physicians, they felt they had experience in coordinating care where they didn’t feel that some of their specialty colleagues were ready to take that on. Several complained about narrow insurance networks that require them to work with specialists who have poor communication and coordination skills, using words like “atrocious” and “radio silent” to describe how they hear back from consultants.

I suppose I was lucky to start my career in the days when my employers supported my ability to refer to the specialists I felt were most appropriate and when most of the specialists in the community were credentialed with nearly all third-party payers. The only payer I had difficulty finding specialists for was Medicaid.

As I determined that a given specialist had poor communication skills or was lacking in follow-up or coordination, they quickly fell off my list of consultants. That got me in trouble more than once with senior members of the hospital medical staff, who complained bitterly that a certain new physician wasn’t giving them the referrals they felt they were due. When I was approached about it by a hospital VP who had been assigned to “mentor” me, I explained that I was referring to the junior partners in their practices who were friendly, collaborative, and actually acted as though they wanted to care for my patients. The fact that I was at least referring to the practice seemed to provide cover, but the idea that a specialist would be “owed” referrals due to seniority or status was (and still remains) offensive.

Referring to the specialists I prefer is a bit more difficult now. Our office gets frequent callbacks from patients who are unable to see the specialists that we recommend due to insurance issues. I try to give patients subtle warnings when I am forced to refer them to physicians I would normally not select. I’ll go ahead and provide multiple referral names, putting the people I prefer at the top of the list. but warning the patient that they need to check with their insurance to determine whether they are covered.

Should the patient choose to go out of network, they can. I explain that the less-desirable provider (without using those words, of course) is more likely to be on their insurance and dance around the fact that although they may have strong technical skills and are a “good surgeon” that the patient might experience some “inconvenience” with the office and getting the paperwork back and forth. I hate to have to use a euphemism for “poor care coordination,” but at least it gives the patient a small bit of warning.

My personal friends who are specialists pride themselves on cultivating their referral base and treating their referring physicians well. Should they decide to pursue recognition, I would foresee their main barriers would be dealing with the documentation requirements from NCQA and educating their staff on any tweaks to process or documentation that may result. I know several of them have unwritten policies for how communication and care coordination occur and they’ll need to get these pinned down and consistent across everyone working in the practice.

Another barrier might be cost. NCQA has a reputation for charging more for the PCMH recognition process than other organizations. Specialists have been fairly insulated from some of the nickel-and-dime treatment that primary physicians have been battling for years, so I’ll be happy to have them on board with our cause.

Others may resist in that they believe they are already providing high quality are and don’t feel the need to have someone else tell them they are. We saw that kind of thinking in the early days of PCMH, but things are getting to the point where physicians almost have to have the formal recognition to stay ahead.

I recently read an article about the CareFirst BlueCross / BlueShield program in Virginia, Maryland, and the District of Columbia. Nearly 90 percent of the plan’s physicians are participating. Those that do receive a 12 percent participation fee regardless of performance metrics and without any penalties or risk assumption. It also treats online visits the same as face-to-face ones. CareFirst’s analysis shows that in looking at 2014 data, participating practices took in an additional $41K in revenue above the participation fee. Additionally, 75 percent of its patients had established a relationship with a primary physician.

The program asks physicians to group together in panels that are graded on patient engagement, access, and appropriate use of services. The engagement score holds the most weight and includes patient satisfaction indicators. The panels of physicians are expected to meet monthly to discuss performance and compare notes.

From the provider standpoint, this sounds like the kind of work we need to be doing to help physicians move forward under new care models. Rather than just tell them they need to do a certain thing or achieve a certain outcome, they’re creating support structures for physicians who can work within the collaborative environment to make changes. Participating providers should also receive reinforcement from their peers when they are doing well, in addition to suggestions for changes proven in other practices.

It remains to be seen whether these types of initiatives will appear in the Patient-Centered Specialty Practice realm. I’ll be watching to see whether specialty physicians start gravitating towards this on their own or whether they’ll only head in that direction when forced to by their employers or other external pressures. I’ll be interested to hear what they think of the process and whether it elicits sympathy for the primary care physicians who have gone before them.

What do you think about Patient Centered Specialty Practice recognition? Email me.

Email Dr. Jayne.

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