For the general population, we need to both educate, and bring back the focus, to primary care.

In a recent AMA Wire article titled “What specialty physicians need in new models of care,” it was reported how the CMS plans to test new care delivery and payment models with specialist physicians. 

“The AMA has been working with specialty societies,” the article reports, “to identify ways patient care can be improved while health care spending care be reduced through new payment models.” While many specialists certainly have unique obstacles and needs, it seems that the CMS would simply be reinventing the wheel with such an initiative.

The Foundation for Patient-Centric Care Management Still is Primary Care

It’s true that specialists must be integrated strategically within any high functioning framework. However, the AMA’s specialty-specific reimbursement model has absolutely no mention of an emphasis on primary care. 

Specialty physicians do often deal with very medically complex patients. Additionally, they likely feel that they are being held accountable for patient outcomes that they cannot easily influence. And, it is true that having a reimbursement structure that does not keep this in mind is not equitable for specialty physicians. 

Looking Forward, Let’s Work to Integrate Specialists for Better Outcomes for All Parties

A major component of an adopted reimbursement model must be an integration element, one that benefits all parties involved. Specialty physicians, in this setup, could consider adding an element that includes integration and communication with the primary care physician. 

This kind of organized, planned and improved way to exchange information is one of the care management support offerings that EngageHealth IQ provides. 

One example of such an advanced workflow strategy is hardwiring the Specialist Nurse with the Primary Nurse Care Manager. Combined with additional revenue opportunities through Transition Care Management (in which the physician can bill the TCM code as well as other services by auxiliary staff), a “high functioning” model should be able to support Complex Chronic Care Coordination. And that’s a reimbursement opportunity for the Primary Care Physician that’s long overdue.

These opportunities will allow for better coordination by Primary Care Physicians and the Specialist point nurses in addition to appropriate reimbursement opportunities for the practice at large. Although currently available, future, and needed reimbursement opportunities, may overlap for many centers.

Ultimately, this “integration element” of a reimbursement model would require specialty physicians to involve primary care physicians in what you could call “shared medical decision making.” Ultimately, the outcomes would include lower costs. In addition, it’s true that it would require patients without a primary care physician who are receiving specialty care to be established with a primary care physician in order to receive that ongoing specialty care.

Taking a Step Back and Looking at the Big Picture 

We’re now faced with the opportunity to reduce silos of care for those only receiving specialty care. Performance measures in the model, in the future, would track how well specialty physicians integrate their care within the context of a primary care patient centered model.

Access of care and true integration across the medical neighborhood with specialists is a vital indicator, and driver, of better health outcomes and lasting success for practices.

It’s not to say that specialty physicians shouldn’t have the opportunity for greater flexibility or risk protection, but as the foundation for total care management, primary care must simply not be overlooked. 

Partnering with physicians, EngageHealth IQ brings clarity and integration to a practice through the following tools:

·      Analysis of active panel of patients (to determine appropriate desired “mix” of patient profiles)

·      Projections for care provider team staffing to see greater returns

·      Team productivity and its implications for optimal revenue and utilization

·      EngageProfit: a proprietary ROI tool for financial analysis, revealing an optimal staffing model, also further enabling a center’s physicians to focus on higher acuity patients 

Interesting in learning more? Get in touch with us today.


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