Pulse
Home Alone
Cold Spring physician Christopher Wenner is the first solo practitioner to obtain health care home certification.
By J. Trout Lowen
Christopher Wenner’s approach to medicine might surprise some of his fellow physicians and make a few others feel nostalgic. Wenner, who opened a solo family practice in the town of Cold Spring outside of St. Cloud a year ago, allots a minimum of 30 minutes for each patient visit, refers to his reception area as the “no-waiting room,” and even makes house calls.
To be able to provide this sort of care in a way that is affordable for his 440 patients, however, Wenner has had to take on a few additional job titles: receptionist, nurse, biller, and coder. “I have no staff. I do everything myself,” he says. “It’s Marcus Welby in 2010 embracing technology.”
Ones to Watch
A new report from the National Academy for State Health Policy includes Minnesota among its list of the 10 states best poised to take advantage of the reforms being brought about by the Patient Protection and Affordable Care Act. States were selected based on their efforts to address five key components of improving quality and efficiency: data collection, aggregation, and standardization; public reporting and transparency of data; payment reform; consumer engagement; and provider engagement. Minnesota was cited for its “landmark” 2008 health care reform legislation, which launched statewide cost and quality data collection, public reporting, a provider peer-grouping project, and public health initiatives. The report is available online at www.nashp.org/sites/default/files/state.
strategies.improve.quality.efficiency.pdf.
State Selected for CMS Demonstration Project
In November, Minnesota was one of eight states selected to participate in a Centers for Medicare and Medicaid Services demonstration project on the effectiveness of the health care home model.
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With the help of an electronic medical record (EMR) system, Wenner has built his practice around a care coordination model, which enabled his clinic to become one of the first in the state—and the only solo practice so far—to be certified as a health care home by the Minnesota Department of Health.
Developed as a result of Minnesota’s 2008 health care reform law, health care homes, also known as medical homes, emphasize an approach to caring for patients with complex or chronic illnesses in which the physician or another provider coordinates the services of a team of clinicians, nurses, therapists, pharmacists, and others in exchange for a monthly per-person payment. As of the end of 2010, the state had certified 47 clinics as health care homes. Most are affiliated with large health systems.
Wenner decided to seek certification because he already was providing coordinated care to all of his patients, not just those with chronic conditions. “My practice is really centered on the medical home model,” he says. “I know my patients well and what their needs are.”
Wenner knows his patients because he connects with them not only at the clinic, but also in their homes, online, or by telephone. “I really want to provide unfettered access to my patients, which I think is key to the medical home philosophy.”
In addition to offering telephone and online consultations, Wenner relies on his EMR to track his patients’ lab results, follow up on referrals, communicate with other members of a patient’s care team, and submit billing and coding information.
Growing Pains
Although Wenner has figured out how to harness technology in order to provide the coordinated care necessary to become a health care home, he’s still struggling with how to get paid for doing so. He says the state’s reimbursement process for care coordination is cumbersome.
Currently, physicians use an assessment tool to group patients who might qualify for health care home payment into one of four tiers based on the number of major chronic condition categories that apply. Each tier has a set per-person per-month reimbursement rate. Physicians invoice the state monthly based on the services they provide to qualified Medical Assistance patients. The care coordination fees range from $10.14 per patient per month for the least complex cases to $60.81 for the most complex.
Wenner says it’s hard to justify spending so much time on paperwork, given the size of the payments. “If being a medical home is a plaque and a pat on the back and that’s it, it’s somewhat of a hollow reward,” he says.
Participating in the program is especially difficult for clinics like his that have no or limited billing staff. “I think I should be recognized for the care coordination that I do,” he says. “I think primary care is grossly underpaid in the realm of medical specialties, and that’s a big part of it. I’m just frustrated that it’s not more straightforward.”
Changes in Sight
Carol Backstrom, who is overseeing the implementation of health care reform for the Minnesota Department of Health, says she understands Wenner’s frustration with the process.
Backstrom says the Department of Human Services and its advisory group looked into the reimbursement system but decided not to go with a less-detailed one because they thought it might discourage providers from taking on patients with more complex health problems. “The intent is really to reward providers for taking on more complicated patients. The more comorbidities a patient has, the higher the reimbursement will be for care coordination,” Backstrom says. “While it may feel cumbersome, this is also an acknowledgement that not all patients are alike.”
Backstrom acknowledges that Medical Assistance, the state’s Medicaid program, is currently the only payer required by law to pay certified health care homes for care coordination. “Certainly it was the intent of the Legislature that this would be an all-payer model,” Backstrom says. “I think it’s going to take some time to figure out how each payer is going to approach this.”
It appears things are beginning to change. Beginning this summer, certified health care homes in Minnesota will be able to apply for care coordination payments for Medicare patients as well as for those on Medical Assistance. Wenner says this move will likely double the number of patients in his practice who qualify for such payments.
Added Value
Despite his frustration with the reimbursement process, Wenner says he will likely seek to recertify his clinic as a health care home next year. He expects the state’s system will improve. And he sees an added benefit to being a medical home. “It’s a marketing tool for me,” he explains. “And now that I’m trying to establish my practice, it’s nice to be able to say that I’m the only certified medical home in central Minnesota.” ■