PRIMARY CARE PHYSICIAN’S MIX OF SERVICES PROVIDED IN A SYSTEMS-BASED PRACTICE ENVIRONMENT

The Affordable Care Act considers the skills needed to provide inter-professional, integrated care through collaboration among health professionals.  Also, training in enhanced communication with patients, evidence-based practice, chronic disease management, preventive care, health information technology, and other competencies as recommended by the Advisory Committee on Training in Primary Care Medicine and Dentistry and the National Health Care Workforce Commission.  In addition, training in cultural competency and health literacy.  The term ‘health literacy’ means the degree to which an individual has the capacity to obtain, communicate, process, and understand health information and services in order to make appropriate health decisions.

Concern:  PCPs doing too much – rather than refer to Specialists, such as for:

  • Allergy testing
  • Suturing, and excision of benign lesions
  • Flexible sigmoidoscopy
  • Fractures
  • Pelvic Exams
  • Lab and Radiology Tests

Because of financial incentives, PCP’s in a systems-based practice environment may render more services than those in a fee for service environment. For example, instead of referring patients for certain type of specialist’s services, PCP’s under managed care, may render such services themselves. PCP’s may be rendering services as if they were allergists, dermatologists, and opthamologists. If the costs of such specialist’s services are part of the capitation amount the PCP receives, then there is the incentive for the PCP to render more of such services. In the same manner, PCP’s may also be financially affected by their hospital admissions.

Some PCP’s argue that they are being required or given incentives by HMO’s to do many low-level specialty procedures that they are not equipped or trained to do. These procedures range from allergy testing, suturing, and excision of benign lesions to flexible sigmoidoscopy, fractures, pelvic exams, and many lab and radiology tests. The number of services is said to be growing rapidly.

Consider:   Providers using their own actuarial studies like Managed Care Organizations (MCOs)  

Primary care guidelines published by Milliman & Robertson, a leading health-care actuarial firm, have turned up in several capitation agreements. Some HMO’s are making primary care doctors responsible for services they’ve never provided before. The American Academy of Family Physicians training courses now address not only minor surgical and orthopedic techniques, but also tests like colonoscopy, upper and lower endoscopy, culposcopy, and obstetrical ultrasound. Current Internal Medicine residency programs teach their trainees the basics of endoscopy, gynecology and minor dermatologic and surgical work.

Malpractice risk increases by PCP’s performing services traditionally reserved for specialists because such PCP’s will be held to the same standard of care as the specialists. However, adding to clinical skills can save referral costs and make such providers more valuable in the eyes of HMO medical directors. Also, exposure to financial risk increases if capitation does not cover the extra services.

Consider:  How much training is appropriate for PCPs and how to certify it?

There is debate going on among various medical education institutions and others about how much training is appropriate for primary care physicians and how to certify it. Also, there has been some federal legislation passed and some states have passed their own legislation aimed at patient protection. Such legislation might include requirements to disclose certain financial incentives which may affect physician’s health care recommendations.

Policing Coding – Some things to watch out for:

  • Physician Evaluation and Management (E&M) Codes: correctly coded and documented
  • Services and supplies incident to physicians’ services: physician billing for services provided by other healthcare practitioners that are a subordinate part of what they do such as physician assistants, nurse practitioners, physical therapists and others
  • Preventive or Related services: Doctors who provide patients with too few or too many preventive or related services will come under the Office of Inspector General (OIG) searchlight for fraud and abuse
  • Consultations: Under Medicare rules, doctors may bill for a consultation if it is made at the attending physician’s request, includes an exam and review by the consulting physician and if the resulting report is made part of the permanent medical record

Movement towards more involvement by patients with their own care

Primary care is not only the point of access for most patients, but the point of opportunity for coordinating the mix of services that each patient may require. If the patient is well, then the managed care health system is typically designed to place that person along a track geared toward promoting and maintaining wellness. If the patient has one or more chronic illnesses, then the managed care health system is typically designed to enlist tools and techniques to manage those conditions across sites and providers of care. Such a system provides consistency and continuity of care, while steering patients toward taking responsibility for improving or maintaining their health, independence and well-being. This type of system emphasizes integration and continuum of care as compared to independence and autonomy. An information structure is vital to the operation of a continuum of care.

Study Fee-for-Service and HMO patterns of care: 

Tend to be similar at both extremes of health – healthiest and sickest patients

Differences in care, “savings” observed for episodes of treating HMO patients with specific disease, appear to occur primarily when treating patients with “average” overall health problems.

It is interesting to note that according to one study Fee-for-Service and HMO patterns of care tended to be similar at both extremes of health; that is, the healthiest and the sickest patients received similar care, with some evidence that the sickest HMO patients tended to receive more resources than the sickest Fee-For-Service patients. According to this study, the differences in care, that is the “savings” observed for episodes of treating HMO patients with a specific disease, appear to occur primarily when treating patients with “average” overall health problems.

Malpractice risk increases by PCP’s performing services traditionally reserved for specialists because such PCP’s will be held to the same standard of care as the specialists

Under the Affordable Care Act (ACA) additional efforts to expand the primary care workforce are underway. New training and retention programs have also been created to develop and strengthen the primary care workforce. The ACA has increased the number of graduate medical education residency programs to support primary care training in ambulatory care settings. Other efforts include investments in training for nurses and physician assistants, and financial support for nurse-managed clinics.

The ACA supports population-based prevention activities through a new Prevention and Public Health Fund. This Fund has been used to make over $1 billion in critical investments in programs aimed at reducing the burden of chronic disease and improving the overall health of communities.

The Affordable Care Act established the Prevention and Public Health Fund to provide expanded and sustained national investments in prevention and public health, to improve health outcomes, and to enhance health care quality.  The Fund has invested in a broad range of evidence-based activities including community and clinical prevention initiatives; research, surveillance and tracking; public health infrastructure; immunizations and screenings; tobacco prevention; and public health workforce and training.

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