AMA House of Delegates

AMA meeting: Delegates back medical home, want pay issues resolved

Physicians decide more discussion is needed on how payment for care under the medical home concept will affect specialists and primary care physicians.

By Doug Trapp — Posted Dec. 1, 2008

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The American Medical Association united with four other physician organizations on principles for how a patient-centered medical home system should work. But it resolved to study further the contentious issue of doctor payment under such a system.

The AMA House of Delegates, at its November Interim Meeting, adopted principles that call for medical home physicians to implement an infrastructure that allows them to have more continuous contact with patients, coordinate care better across the entire health system and use more evidence-based medicine to guide clinical decision-making, among other responsibilities. The principles state that the doctors in turn should be paid additional fees that appropriately reflect the added value these commitments provide to patients.

In endorsing the principles, the AMA follows in the footsteps of the American Academy of Pediatrics, the American College of Physicians, the American Academy of Family Physicians and the American Osteopathic Assn. These societies first adopted the joint principles for a patient-centered medical home in February 2007.

Samantha L. Rosman, MD, AMA Board of Trustees member, thanked the societies for their leadership on the issue. "We're very proud to sign on to these principles and ... to study further how this can realistically be funded and put into place more broadly."

The move was the right one to make because physicians haven't been focused enough on the total health of patients, said Jim King, MD, AAFP board chair. "We're talking about someone taking responsibility for our patients."

Testimony during a committee hearing considering the policy change generally supported the concepts of better coordinating care and improving pay for this work. But tensions arose when some delegates brought up the possibility that medical homes might shift physician pay away from specialists to primary care doctors. Aaron Spitz, MD, a delegate for the American Urological Assn., said he feared that establishing a system of medical homes would not increase overall physician funding. "That will give us a home divided against itself, which cannot stand," the California urologist said, potentially leaving primary care physicians in a "medical home alone."

John H. Armstrong, MD, a delegate for the American College of Surgeons and a former AMA trustee, said the principles should specify that the establishment of medical homes must be accompanied by an overall increase in physician pay, not simply a shifting of dollars. "Can the house of medicine agree -- including primary care -- that this is the approach to take when looking at the medical home?" he asked.

Specialist physicians may have cause for concern about the effect of medical home pay revisions as Democrats in Congress plan a major push for health system reform in 2009. A detailed reform proposal released Nov. 12 by Senate Finance Committee Chair Max Baucus (D, Mont.) calls for additional Medicare payments for primary care physicians, but with corresponding cuts to specialist pay. A Baucus staffer, speaking on condition of anonymity to discuss the proposal freely, said the plan is what Baucus would like "in an ideal world" but that it might be too controversial among physicians. The plan does state that a payment change this significant would need to be crafted with the support of the entire physician community.

However, supporters of the House of Delegates resolution noted that specialists also could provide medical homes. "We're not asking that a patient has to stay in the same home every stage of their life," Dr. King said. He noted, for example, that a specialist coordinated the care when his father was diagnosed with renal failure.

Also, the AMA can embrace the organized medicine principles without specifying the funding mechanisms right away, said William E. Golden, MD, an ACP delegate. "We're not asking for that today to be solved. That's going to be for future discussions."

Additional physician pay could come from savings generated in Medicare by providing better care that prevents or reduces chronic illnesses and hospital visits, delegates said.

Physicians curious about how a medical home program might work should examine North Carolina's Medicaid program, said Charles F. Willson, MD, a pediatrician and alternate delegate for that state's medical society.

More than 800,000 North Carolina Medicaid recipients are enrolled in one of 14 physician-directed care networks in the state. A doctor receives $2.50 per Medicaid enrollee per month to manage their care. The program does not pay based on performance, but the state issues confidential quality reports to physicians.

The program's additional pay eases financial pressure on doctors' practices, which in turn allows the physicians more easily to care for the uninsured, Dr. Willson said. "This is a strong, strong concept."

Specialist physicians unsuccessfully tried to amend the medical home resolution on the house floor so it would have the AMA and all interested medical societies seek additional medical home funding beyond existing Medicaid and Medicare dollars. That proposal also called on the Association to ensure that medical home patients can access specialists without interference and guarantee that patients can select any qualified physician practice as a medical home. The house referred the amendment to AMA trustees for further review.

The AMA's work on medical homes has just begun, Association leaders said. The adopted resolution requested that the AMA continue to study the patient-centered medical home concept, with particular attention paid to "funding sources and payment structures." The AMA Council on Medical Service plans to report to the house on medical home physician payment at the 2009 Annual Meeting.

Dr. Rosman said the Association is sensitive to specialists' concerns about potential reduced payment under the medical home. "We certainly don't want to sacrifice any other part of patient care to fund this."

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ADDITIONAL INFORMATION

The medical home model

The AMA last month joined the American Academy of Pediatrics, the American Academy of Family Physicians, the American College of Physicians and the American Osteopathic Assn. in adopting joint principles for a patient-centered medical home, including:

Care coordination: Each medical home patient has an ongoing relationship with a personal physician trained to provide first-contact, continuous and comprehensive care, coordinated across all elements of the U.S. health system.

Physician pay: Medical home payments reflect the value of care-management work conducted by physicians and staff beyond face-to-face visits. Payment is available for use of health information technology as well as secure e-mail and telephone consultations. Doctors share in the savings from reduced hospitalizations. Additional payments are available for medical homes that achieve measurable and continuous quality improvements.

Quality and safety: Medical homes seek optimal patient outcomes defined by a care-planning partnership among physicians, patients and their families. Doctors follow evidence-based medicine and actively seek patient feedback. An appropriate nongovernmental entity certifies practices seeking to become medical homes.

Access: Enhanced patient access is available through open scheduling, expanded hours and new communication options among patients, their personal physicians and medical home staff.

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Meeting notes: Medical practice

Issue: Physicians who work in multiple locations or states and prescribe controlled substances must use multiple Drug Enforcement Administration registration numbers, which create additional administrative work.
Proposed action: Work with the DEA to allow physicians to have unique, person-specific DEA numbers. [ Adopted ]

Issue: Physicians are concerned that TRICARE is not providing adequate quality care -- especially mental health care -- to eligible servicemen, military retirees and their families.
Proposed action: Support increasing TRICARE physician payment, especially for mental health and addiction services. Encourage TRICARE officials to recruit more mental health treatment professionals and improve physician education on care coordination. Urge TRICARE officials to pay more for childhood vaccines. [ Adopted ]

Issue: Certain nonphysicians with advanced degrees (such as PhDs) confuse patients and hospital staff by referring to themselves as doctors.
Proposed action: Ask hospitals to require that staff who are not MDs or DOs identify themselves to patients as nonphysicians. [ Adopted ]

Issue: Many graduating medical students who intend to practice in underserved areas find that financial and other barriers discourage them from doing so.
Proposed action: Advocate for loan repayment programs, scholarships and tax credits for physicians serving these communities, as well as for reauthorization and expansion of the J-1 visa waiver program. Study and report back in 2010 on what medical schools are doing to attract students who will work in underserved areas. [ Adopted ]

Issue: Physicians with low patient volumes -- including young physicians -- face difficulties obtaining or keeping hospital credentials.
Proposed action: Study the challenges in credentialing low-volume physicians and develop appropriate criteria and methods for doing so. [ Adopted ]

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