Primary Care Physicians Take Note Of Reform Possibilities

Physicians everywhere generally seem most concerned with the managed care aspects of healthcare reform. There is a fear that, with the movement into a marketplace where there are more insureds (either through employer mandates or Medicaid eligibility expansion) and the growth of risk based compensation, panic is close at hand. Physicians, especially primary care physicians, need to be more circumspect and look for a silver lining.

First of all, the sky is not falling. It is changing, as it always does, but it is not falling. It is axiomatic to think that change in health care is inevitable. Of course it is. It is foolish, however, to think one knows precisely what it will consist of. That said, it is fairly predictable that, if the healthcare reform laws are even just a sign of what’s ahead, the future may have the following characteristics in the insured (governmental or commercial) market:

1. A movement over time away from fee for service payment;
2. Growing integration of information technology (e.g. EMR) into healthcare;
3. Increased outcome-based measurement and connection to reimbursement; and
4. Healthcare businesses and physician practices combining in various ways.

Some experts have said “we’ve been here before.” Remember the capitation, IPA and PHO explosion of the 90s? True enough, but there was never any discussion about tying reimbursement to quality measures of any kind back then. The things they are unified about, however, are the need to develop compensation methodologies which accomplish three things:

1. Get more patients insured;
2. Slow the rate of increase in healthcare expenditures; and
3. Measure quality.

Though the fears about the methods proposed for accomplishing those three objectives are understandable, and while physicians do have to explore how they are doing business (in the insured marketplace) and do need to consider alternatives (e.g. IPAs, practice mergers), there is little conversation about the more proprietary opportunities presented to physicians in the face of reform.

Healthcare reform will likely create tremendous opportunities in the “proprietary marketplace,” where business opportunities abound. Some experts even say that the reform changes will amplify a growing two-tiered system that already exists in our culture. What that looks like is impossible to predict, but there are at least two signs and signals that exist today.

Patient centered medical homes (PCMH). The term was first coined by the American Academy of Pediatrics in 1967. Since then, the concept has morphed with the input of the American Academy of Family Physicians and the American College of Physicians. Simply put, the PCMH or simply Medical Home is not home health care. It is an expanded concept of how to deliver primary care and ensure patient participation in their care and outcomes. The concept includes some basic elements:

1. It is located in a lower cost environment closer to patient populations to ensure access;
2. It has expanded hours to accommodate patient schedules;
3. It is primary care led, using both physicians and others;
4. It expands on the concept of care delivery to include relevant and necessary services such as serving as a nexus between patient needs and the community;
5. It uses enhanced communication techniques, like texting patients about appointments and online scheduling;
6. It takes into consideration patient lifestyle to ensure enhanced patient participation;
7. Evidence based medicine and outcome demonstration is at the core.

Regardless of how the model is interpreted or implemented, one thing is clear: there is a business opportunity here!

Concierge practices. Many experts agree that the already existing two tiered medical system in our culture will expand as the insured market grows. More and more patients, they say, will want greater access and “non-covered services” (especially as the definition changes of what is covered what is not). Again, opportunity!

Physicians have a tall order now: Consider new ways to adapt and prosper in an expanding insurance market. They also need to keep in mind the opportunities the market changes present.