Patient-Centered Medical Home (PCMH) Q&A
What Is a Patient-Centered Medical Home?
A patient-centered medical home is an approach to providing comprehensive primary care for people of all ages and medical conditions. It is a way for a physician-led medical practice, chosen by the patient, to integrate health care services for that patient who confronts a complex and confusing health care system. The American Academy of Pediatrics (AAP) introduced the medical home concept in 1967, initially referring to a central location for archiving the medical records of a child. In its 2002 policy statement, the AAP expanded the medical home concept to include these operational characteristics: accessible, continuous, comprehensive, family-centered, coordinated, compassionate, and culturally sensitive care. In February 2007, the AAP, the American Academy of Family Physicians (AAFP), the American Osteopathic Association (AOA) and the American College of Physicians (ACP) used this 40-year old concept to develop a set of joint principles that describe a new level of primary care which they call the Patient-Centered Medical Home. These principles address the medical home partnership through which access is facilitated to specialty care, educational services, out-of-home care, family support, and other public and private community services important to the overall health of the patient.
The Patient-Centered Medical Home
The patient-centered medical home (PCMH) is a model of health care delivery that is based on an ongoing personal relationship with a physician. This personal patient/physician relationship provides continuous and comprehensive health care.
A medical practice that operates as a PCMH consists of the personal physician leading a team of health care professionals who collectively take responsibility for the ongoing care of the patient.
A whole person orientation is a key component of the PCMH. The personal physician is responsible for providing for all the patient’s health care needs or taking responsibility for managing care with other qualified professionals. This includes care for all stages of life; acute care; chronic care; preventive services; and end-of-life care.
Care is coordinated across all elements of the patient’s community including the health care system (hospitals, home health agencies, nursing homes, consultants and other components of the complex health care system), facilitated by registries, information technology, health information exchange and other means to assure that patients get the indicated care when and where they need and want it.
Quality and safety are hallmarks of the patient-centered medical home. Physician practices that adopt the PCMH model become advocates for their patients to support the attainment of the best health outcomes. These outcomes are defined by a care planning process driven by a compassionate and robust partnership between the patient, the patient’s primary physician, other physicians, health care providers and family members. The patient actively participates in decision-making and provides feedback to ensure expectations are being met.
Evidence-based medicine and clinical decision-support tools guide decision making. Physicians in the practice accept accountability for continuous quality improvement through voluntary engagement in performance measurement. Information technology supports optimal patient care, performance measurement, patient education, and enhanced communication.
This enhanced access to health care means the practice provides patients with options such as open scheduling, expanded hours and various arrangements for communication between patients, the physician, the practice team and office staff.
Does a PCMH Work?
Community Care of North Carolina is a working example of a PCMH. The program shows excellent quality and cost outcomes through disease management, evidence-based clinical practice, and an emphasis on a physician-led team approach. Community Care of North Carolina is the state’s Medicaid program. Two independent evaluations of this program indicate it has saved the state $195 to $215 million in 2003 and between $230 and $260 million in 2004 when compared to historical fee-for-service. States and localities like Louisiana, Massachusetts, Minnesota and Washington, DC, are developing legislation to implement medical home pilot programs. Additionally, Section 204 of the federal Tax Relief and Health Care Act outlines a Medicare Medical Home Demonstration Project. This three-year project will involve care management reimbursement and incentive payments to physicians. It will evaluate the health and economic benefits of providing targeted, accessible, continuous, and coordinated, family-centered care to high-need populations. A PCMH also addresses issues of health disparities. According to the new Commonwealth Fund report, Closing the Divide: How Medical Homes Promote Equity in Health Care, when adults have health insurance coverage and a medical home, racial and ethnic disparities in access and quality tend to disappear. The analysis--based on a Fund survey of more than 2,830 adults nationwide--reveals that linking minority patients to a medical home can help them better manage chronic conditions and obtain critical preventive care. The PCMH is gaining recognition among the private sector as well. UnitedHealthCare and IBM are working with the AAFP to implement medical home demonstration projects across the country. In mid 2007, as a way to promote the revamping of the American health care system, several large employers joined with AARP and other consumer groups and with the four primary care physician organizations to organize the Patient-Centered Primary Care Collaborative. The goal of this group is to promote the PCMH as a most effective tool for improving health care quality for the patient and reducing costs for both the payers and the patients.
Recognizing a PCMH
Physician practices go through a voluntary recognition process by an appropriate non-governmental entity to demonstrate that they have the capabilities to provide patient centered services consistent with the medical home model. The National Committee on Quality Assurance, for example, has worked with the primary care physician groups to develop a multi-tiered recognition process. The Patient-Centered Primary Care Collaborative is working with the insurance industry and federal agencies and Congress to provide these recognized PCMH practices with appropriate compensation.
How Are Physicians Compensated Under the PCMH Model?
The PCMH appropriately recognizes the added value provided to patients who have a patient-centered medical home. The payment structure should:
- Reflect the value of physician and non-physician staff work that falls outside of the face-to-face visit associated with patient-centered care management.
- Pay for services associated with coordination of care both within a given practice and between consultants, ancillary providers, and community resources.
- Support adoption and use of health information technology for quality improvement.
- Support provision of enhanced communication access such as secure e-mail and telephone consultation.
- Recognize the value of physician work associated with remote monitoring of clinical data using technology.
- Allow for separate fee-for-service payments for face-to-face visits. (Payments for care management services that fall outside of the face-to-face visit, as described above, should not result in a reduction in the payments for face-to-face visits.)
- Recognize case mix differences in the patient population being treated within the practice.
- Allow physicians to share in savings from reduced hospitalizations associated with physician-guided care management in the office setting.
- Allow for additional payments for achieving measurable and continuous quality improvements.
A focal point of the PCMH is that payment does not depend on expensive and time-consuming face-to-face visits. The team approach with online care and group visits create efficiencies that should lower the cost of care for most patients while affording physicians more time to provide the quality care their patients and payers deserve.
Why Is the PCMH Model Important?
The U.S. health care system currently produces poorer health outcomes at much greater costs than do the health systems of other industrialized nations. Payers and patients alike are looking for better value in health care and desire better quality at lower cost. A recent report, Financing the New Model of Family Medicine (2004), estimates that if every American had a medical home, health care costs would likely decrease by 5.6 percent, resulting in national savings of $67 billion dollars per year, with an improvement in the quality of the health care provided. From AAFP.org
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How Identity Theft Can Affect You
By Jordan Buschmohle, iSekurity
Identity theft is the fastest growing crime in the United States, claiming millions of new victims each year. Every three seconds, someone’s identity is stolen. Everyone is vulnerable. Identity theft is devastating and can take, on average, 330 hours to reverse the damage done to its victims and cost, on average, $4,500 per year, per incident.
Although the crime of identity theft has been around for many years, it has only been within the last five years that the reported incidents have grown to a rate deemed a national crisis. The Federal Trade Commission has declared identity theft an epidemic, and predicts that every US resident will be affected by identity theft at least once by the year 2010.
Most people believe that identity theft is simply about credit fraud. Identity theft is actually about a breach of your personal information and the subsequent use of that information to:
• Gain employment
• Open new credit or accounts in your name
• Buy homes or vehicles in your name
• Gain access to your personal banking accounts
• Open utility accounts
• Use your health insurance
• Commit crimes in your name
Identity theft can happen in numerous ways. Some of the most popular means are:
□ Dumpster Diving: Rummaging through trash for bills or other papers with your personal information
□ Skimming: Using a device to illegally capture credit and debit numbers
□ Phishing: Sending email fraudulently presented as coming from financial institutions, that ask for personal information
□ Using a Change-of-Address Form: to divert your billing statements to another location
□ Old Fashioned Stealing: Stealing wallets, purses, mail such as pre-approved credit card offers, tax statements, and personal records.
□ Cyber Crimes/Stealing of Intellectual Property: Stealing of digital backup data, hacking into corporate servers, stealing laptops and downloading information onto your computer and grabbing sensitive data.
Medical Identity theft has also spiraled out of control, claiming more than half a million victims each year. Unlike traditional identity theft, medical identity theft is very difficult to detect and, if you are a victim, it’s much more difficult to repair its damage. Every time a thief uses your medical identity to obtain medical care, records are created with his medical information that could be mistaken for yours—a different blood type, a history of drug or alcohol abuse, test results that aren’t yours, or a diagnosis of an illness you don’t have. Unlike credit reporting agencies, health care providers are not required to delete or correct incorrect information on your medical records.
Crimes relating to Identity theft have accelerated in 2008, and are expected to worsen in 2009. In addition to traditional methods, criminals are using more sophisticated schemes targeting the unemployed, consumers with poor credit and homeowners facing foreclosure, especially in our troubled economy, according to a report issued by the Identity Theft Resource Center, a national advocacy group of experts based in San Diego, CA.
Once you become a victim, it is your responsibility to pick up the pieces and put your life back together, one step at a time. This process can take years. Statistics from the United States Secret Service show that, on average, once your identity is stolen, it is used up to 30 times. This is due to the simple fact that no one is pursuing the criminal. Yet, the only way to truly stop the identity theft is to attack the problem at its source by investigating the crime and locating the perpetrator. Local, State and Federal government authorities do not have enough resources or manpower to actively combat the crime. Without the proper law enforcement in place or the appropriate amount of resources allocated to fighting it, identity theft will remain the fastest growing crime in America.
What You Can Do
In addition to protecting your personal information carefully, you can also take advantage of two free resources to deter identity theft crime: credit monitoring services and fraud alerts.
· Monitor your credit by visiting annualcreditreport.com. (You can also pay a service provider between $10-$30/month to monitor your credit for you.) Credit monitoring will not stop identity theft from occurring. It’s an after-the-fact notification that you already have a problem.
· Fraud alerts were created by the Federal Government and the three major credit bureaus. You can set these up free of charge by visiting one of the three major credit bureau websites. A fraud alert can be helpful in preventing new credit accounts from being opened in your name for: a credit card, car or home loan, line of credit, cell phone or utility account, etc. The system is not foolproof, because it is the merchant’s responsibility to follow through on what the alert is intended to do. When attempting to open a new account, the merchant should see the fraud alert and stop the transaction before it takes place. Unfortunately, because this alert is located near the back of your credit report, and the system does not legally obligate the merchant to halt the transaction, fraud alerts do not always work.
Keep in mind that even if credit monitoring or fraud alert systems worked perfectly, they don’t prevent all forms of identity theft. They do not stop an individual from using your information to obtain medical procedures, liquidate your savings account, gain employment and subsequently leave you with IRS debt, or commit insurance fraud or other crimes.
iSekurity is a New Hampshire Medical Society Corporate Affiliate, and a national provider of identity theft protection. The company employs the largest team of former federal agents from the United States Secret Service, FBI, DEA, ATF, IRS, Customs, and Postal Inspector agencies, and is committed to aggressively investigating crimes of identity theft against its members.
For more information on iSekurity, please contact the company at: (877.838.5734) or visit www.nhms.org/affiliates.
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Start by Building Castle Walls
Herbert K. Daroff, J.D.,CFP®
www.baystatefinancialplanning.com
hdaroff@baystatefinancialplanning.com
Protecting assets and income from creditors (predators) is important to all of us, but especially to those of us who feel more exposed to liability (e.g., physicians, attorneys, accountants, etc.). However, who among us is not susceptible to such liability risks? As long as you drive a car, or in any other manner interface with others, you should have concerns about the frequency and severity of the liability risks for which you may be responsible.
The tools for Creditor (Predator) Protection, as for any risk management, are Insurance, Hedging, Transferring, and Retention.
Liability insurance includes Errors and Omissions (E&O) or malpractice coverage. Many of us also serve on volunteer boards. Keep in mind that you may be personally liable in that capacity. Therefore, consider Directors and Officers (D&O) coverage. Liability Umbrella coverage is part of your Homeowners policy and is very reasonably priced for what it provides. Though the severity may be substantial, the frequency is very low.
Retaining liability risk may result from simply not identifying that you had the risk exposure. The umbrella coverage may save you from retaining unknown risks.
Transferring risk starts by building castle walls around your assets and your income. Then, dig a moat around the castle walls and fill the moat with rabid alligators. Follow that with a barbed wire fence and then electrify the fence. But, then, don’t leave the drawbridge down!
Risk Transfer includes both onshore and offshore enterprises. Corporations (S, C, and P.C. are limited liability entities for their stockholders. However, the veil of limited liability (castle walls) can be pierced (drawbridge lowered) and your personal assets can be exposed if you act outside your authority as an officer, not just an owner.
| Even as a stockholder, your personal assets can be exposed if you don’t maintain the formalities of the corporate form and treat the assets and income as yours personally. The same is true for the Limited Partners in a Limited Partnership and the Managers and Members of a Limited Liability Company.
Most trusts, however, have little or no creditor (predator) protection. However, properly drafted asset protection trusts are very valuable tools in the battle to protect your assets and income from liability risks. Irrevocable trusts can be created that are intentionally defective for either income tax purposes or estate tax purposes to shelter assets (e.g., Medicaid Trusts) and yet still provide lifetime use of the assets.
Third party trusts (those created for you by others, such as parents) can have significant asset protection. They create strong castle walls. A physician’s parents could establish a trust for the benefit of their child, for example.
But, what do most of these trusts (e.g., irrevocable trusts) provide after the death of the grantor (creator of the trust) or primary beneficiary? That when the children (or grandchildren) attain specified ages we make out right distributions, which will lower the drawbridge and let the creditors in. Leaving assets in trust (behind the castle walls, moat, and electrified fence) should be communicated to your heirs as a shield to protect them even after you are gone. It should not be considered a weapon against the children because you don’t trust them, unless that is the case.
Many clients express the concern that they don’t want their daughter’s next husband (or son’s next wife) to be able to get a dime of what they created. The castle walls are designed to respond to such a planning objective.
Hedging is the use of multiple limited liability entities in combination. Family Bank© involves irrevocable trusts as members of multiple LLCs (or a Series LLC, or LLC Holding Company) that hold individual assets.
©all rights reserved, Herbert K. Daroff, J.D., CFP®
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