February 2012: Medical Homes and the Future of Primary Care under Health Reform

By Lorilee Schoenbeck, ND
AANP Board Member and VANP Past-President

Much of the federal health care reform language about medical homes and primary care has been modeled after Vermont’s current programs. As such, I would like to share what’s happening in Vermont and how this might affect the national landscape for NDs.

If you currently take insurance reimbursement or plan to some day, the structure of reimbursement, the relationship to the greater health care delivery system, the way you chart, and other factors may be profoundly altered. This will particularly be the case for those NDs who consider themselves primary care physicians.

Primary Care: Although state programs will of course vary, the new systems will focus on directing health care by promoting primary care. For example, by as soon as 2011, all Vermont citizens will be expected to have a primary care provider (PCP). This PCP will be the central hub to coordinate their other care, whether mental health, diabetes educators, social work, physical therapy or specialty care. The PCP will head what is called a “medical home,” which means that the clinic coordinates all the care that patient might need.

Medical Homes: Medical homes were created to promote family practice medicine. The idea is based on the understanding that conventional health care delivery is “disease care,” rather than “health care,” ignoring prevention and management of chronic illness, the main cost driver of health care. Medical homes consist of a primary care practice and relationships with allied health care workers (MSWs, RNs, NPs, Medical Assistants, health coaches, nutritionists, etc.) collectively called a “Community Health Team.” These professionals are paid considerably lower fees than “the doctor” and provide support to the MD/DO who directs the care. The availability of additional funding is planned for Medical Homes to aid in administrating/coordinating patient care.

NCQA: The Medical Home Model is currently being promoted and accredited by a national, private organization called the National Committee for Quality Assurance (NCQA). Prior to the efforts of Vermont, the NCQA did not acknowledge or “assess and score” NDs as Medical Home applicants. However, now through our state’s health reform agency, we have been successful in having NCQA assess our clinics to provide scores. To date the NCQA has not formally certified NDs. The assessment is a major breakthrough and one we continue to use with our state legislature to gain recognition.

The current requirements for clinics that want to become recognized as Medical Homes involve a scoring system. We have the current requirements on file if you require a copy (not all areas need be satisfied but a clinic must be moving toward those goals).

Reimbursement: To promote primary care, in addition to a fee-for-service billing like we currently have (you bill a 99214, you get $110), primary care clinics likely will be paid more based on the number of primary care patients they manage. There will be additional payments if they succeed in keeping patients healthy (actually lower patients’ blood sugars, blood pressures, cholesterol, HgA1c, etc.). Of equal importance, the PCPs will be encouraged to keep their referrals for supportive care within their Medical Home/Health Team. They may lose money by referring patients to providers outside their Community Health Team. This could affect any private, independent social workers, counselors, physical therapists, etc., or any naturopathic physicians who remain outside of a Medical Home. In this model, all visits to NDs would potentially need to be referred by the MD/DO who directs the medical home. Of particular concern would be if a primary care ND who is not the patient’s medical home director. They would need to receive a referral from the patient’s MD medical home director, in order to see a patient – even for primary care. The likelihood of receiving referrals in this manner would be challenging, at best.

Summary: Health Care Reform provides many challenges, changes and opportunities for NDs. Health Care Reform will be centered around promoting primary care. The Medical Home is the model regarding how patients will access the medical system (through a primary care provider) with the most traction. Currently, the group that accredits Medical Homes does not recognize NDs, but has agreed to “score” NDs in Vermont only. If you, your state organization, or any contacts in government are interested in seeing NDs become eligible to apply for Medical Home status, please contact Lorilee Schoenbeck ND, who is helping with efforts to get NDs recognized by the NCQA. At one time, PA’s and NPs were not recognized by the NCQA. Pressure from the states and state legislation changed this policy. NCQA recognition may be a way “in” through health care reform for NDs wanting to maintain their status as a PCP.