The shift to value-based care — or a pay-for-performance model — is reforming the health care industry.
It is driving changes in patient treatment and reimbursements for services.
Today, health care providers are paid per service, regardless of patient outcomes.
"In the future, providers will be paid less or nothing at all if the outcome isn't met," said Dr. Jim Tidwell, Owensboro Health vice president of population health.
Several states already use reimbursement programs that pay incentives to doctors, hospitals and clinics that meet performance criteria.
To improve patient outcomes and prepare for anticipated reimbursement changes, four OH primary care clinics became certified last year as patient-centered medical homes by the National Committee for Quality Assurance. Another nine OH clinics, including family medicine, internal medicine and pediatric practices, are working toward that certification.
So what are patient-centered medical homes and how do they figure into value-based care?
Many patients today are medical nomads. Instead of choosing a primary care provider, they hop between emergency departments and urgent care clinics. Those visits can cost more, and patients likely see different doctors at each visit, which translates to no continuum of care.
By contrast, patient-centered medical homes provide a higher level of care. Tidwell calls it "surrounding a patient with support."
To begin with, there's a focus on the relationship between patients and providers.
Using this model, providers serve as patient advocates who oversee medical needs, make referrals and coordinate services with other physicians when needed. Patients are encouraged to be engaged in their treatment plans, which leads to better management of chronic conditions.
Patients in the patient-centered medical home setting tend to receive more preventive services and screenings.
At OH, primary care clinics offer care navigators, who make follow-up calls to ensure patients understand a doctor's instructions and how to take medications. Eventually, Tidwell would like to place care navigators at every OH clinic.
"A growing body of scientific evidence shows that (patient-centered medical homes) are saving money by reducing hospital and emergency department visits, mitigating health disparities and improving patient outcomes," the NCQA reports.
The idea of certifying patient-centered medical homes started in 2008 — at the request of the American Academy of Pediatrics, American College of Physicians, American Osteopathic Association and American Academy of Family Physicians. Since then, the program has gone through two major revisions.
According to a June 2019 NCQA report, the use of patient-centered medical homes reduced emergency room visits for Medicaid and Medicare patients, compared to health systems that did not use that model. Also, certified facilities lowered overall Medicare spending per patient.
Kayla Wagner is the OH practice manager for Family Medicine Breckenridge, palliative care and pediatric hospitalists. She is the health system's NCQA patient-centered medical home certified content expert.
As such, she is one of only eight in Kentucky. Others work in Louisville, Lexington and London.
As of Oct. 15, Wagner said, the state had 220 clinics certified as patient-centered medical homes.
"... That 220 clinics may seem like a large amount," she said, "but it's actually a small percentage of the total number of primary care clinics registered in the state of Kentucky."
It took more than a year for OH's primary care clinics to become certified. Achieving that milestone is not the end of the road, however.
"We're constantly having to improve and ensure we are providing the highest quality of care," Wagner said. "If you can't prove that, your certification is removed."
Renee Beasley Jones, 270-228-2835, email@example.com