Currently, the U.S. spends more than $2.8 trillion a year on healthcare, and 30% of that is considered unnecessary spending. The United States is greatly in need of a more efficient healthcare system. Many healthcare leaders believe that implementing Primary Care Medical Homes for all patients is the best way to improve the quality of healthcare, while also decreasing the cost of healthcare. Insurers are driving a transformation to Primary Care Medical Homes by creating plans that pay reimbursements based on patient-centered services.
Patient Centered Medical Homes (PCMHs) are a care delivery model that attempts to improve healthcare efficiency by joining the efforts of and improving the communication between all healthcare team members treating a patient. A patient’s care is dictated by his or her primary care provider, and coordinated between all members of the healthcare team. This model is not a new concept—it was originally developed in 1967 by the American Academy of Pediatrics to treat children with multiple medical needs.
Five key characteristics are at the core of the Patient Centered Medical Homes model:
- Patient-centered. PCMHs focus on the unique healthcare needs of an individual so he or she receives the specific care needed to be well.
- The members of a PCMH team work together to address all care needs, from preventive care to the management of chronic conditions.
- PCMHs offer shorter wait times for appointments, as well as care after hours using 24/7 phone or internet tools.
- Using electronic medical records, all members of a PCMH team communicate with each other to prevent unnecessary or duplicate tests and treatments.
- Committed to quality and safety. All members of a patient’s medical team must ensure quality care and patient education for proper treatment and health management.
How does this model affect physical, occupational, and speech therapists?
Many therapists welcome the patient centered medical home model, because of its attempt to treat the patient as a whole, rather than the sum of their parts. Therapy plays an integral role in preventing health crises, and can provide significant savings when utilized as an option that might prevent surgery. PCMH’s give recognition to the important role that therapists play in helping patients long after the acute phase of their health crisis is over. Improving communication between all the providers in a patient’s care, including rehabilitation, is definitely to the therapist’s advantage. Therapists who embrace PCMH must be able to work effectively with primary care physicians and other members of the healthcare team for efficient, appropriate patient care. Rehabilitation Facilities are already adapting to the use of electronic medical records, encouraging preventive care measures as well as sick care, and understanding and embracing the PCMH as a care delivery model.
One way to embrace the PCMH concept is through participation in an accreditation or certification program. National organizations, such as the Accreditation Association for Ambulatory Health Care (AAAHC), the Joint Commission, the National Committee for Quality Assurance (NCQA) and the Utilization Review Accreditation Commission (URAC) offer programs for PCMH recognition. Though only about 7,000 practices currently have PCMH recognition, insurance companies are currently building PCMH-centered products, and marketing the advantages of these programs to employers as a way to help ensure high-quality care and eliminate wasteful medical spending. Participation in a PCMH could enhance the reputation of a facility and the way it does business. Of course, facilities must weigh the benefit of such recognition versus the process and costs associated with accreditation programs.
Difficulties and Questions about Patient Centered Medical Homes
No transition is easy, and the success of this transition to PCMHs depends on whether reimbursements are adjusted to reward physicians and other health care providers who provide preventive care, as well as acute services. In the past, therapists have not been seen as a medical necessity, and insurance plans often excluded coverage for their services. Under the ACA, health plans must cover 30 visits a year of each of type of rehabilitation, including physical, occupational, speech. Rehabilitation providers have yet to see an increase in demand for their services, as the ACA plan deductibles and out of pocket costs are so high, some patients can’t afford the cost of therapy, even though they have insurance.
Another area of concern is that bundled services will exclude independent therapists from receiving referrals. As hospitals and regional healthcare providers merge to be eligible for bundled reimbursements, small, stand-alone clinics are left with a dilemma. Although it’s illegal for physicians to own rehabilitation centers and self-refer patients to their clinics, PCMH’s may cause confusion in the patient’s understanding of the relationship between their physician and their rehabilitation provider. Patients are free to have rehabilitation at any facility, but they may not receive adequate information about all the options.
And finally, physical therapists have lobbied hard and long in many states to get their state government to recognize their education as having similar status to a physician, and pass legislation that allows them to see patients with out a physician’s referral. However, insurance companies still require a physician referral before they approve reimbursement, so these gains in independence haven’t led to an increase in patient visits. Emphasizing the physician’s office as a medical home runs in the opposite direction of these legislative efforts, emphasizing collaboration instead of independence..
What have your experiences been with Patient Centered Medical Homes?
As you move your facility forward toward the future of healthcare, what advice do you have for your fellow therapists? At PT Solutions, we work with hundreds of therapists and facilities as they work to adjust to the changes in our healthcare delivery system.
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Your experiences can help us all navigate the challenges that are before us.
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