Decades later, the grown-up Volpe-who's certified in pediatrics, geriatrics and internal medicine-is attempting to recreate that type of doctor-patient relationship in his own solo practice in Staten Island, N.Y.
There are a couple of key differences. Volpe documents his care with an electronic health record, having abandoned the paper charts ubiquitous during the Welby era. And unlike Welby, who practiced in an era all but devoid of pre-authorizations, high deductibles and insurance plan second-guessing, Volpe must contend with the economic realities of modern medicine. That's why he has fashioned his practice around the "patient-centered medical home" model of care delivery. The model-in place at a growing number of primary care practices-attempts to temper the volume-based mania of fee-for-service medicine with a preventive approach designed to be more meaningful-and effective-for patients and physicians alike. The model can also reduce care costs, which is why growing numbers of payers are incentivizing it.
In the medical home model, the primary care practice is the quarterback for a patient's care, coordinating services outside the practice, tracking outcomes, trying to reduce unnecessary expenses and potentially share in the rewards for doing so. Some medical home practices are even eyeing at-risk payment contracts.
Volpe describes the emerging care delivery model this way: "A medical home is like a real home," he explains. "If you live in a home, everyone cares about everyone else. Everyone in the home pitches in to make sure everyone succeeds. You migrate that idea to the physician office. So the front desk isn't brusque with people and the staff asks patients about their families, about the daughter who just went to college."
But the bar is set pretty high for practices trying to earn medical home designation. Attaining medical home status the National Committee for Quality Assurance-the industry's gold standard, one recognized by both CMS and commercial payers-requires meeting not only hefty I.T. requirements but upending traditional staff roles to boot. Those I.T. requirements include an EHR as an absolute prerequisite for more sophisticated versions of the model, with a patient portal, data exchange, and analytical capabilities running a close second.
In many ways, the medical home is the industry's testing ground for a connected industry. Physicians who embrace it say they can meet the so-called "triple aim" goals touted by the federal government of better care, better access and better outcomes.
Humble beginnings
Although versions of the medical home date to the late 1960s (the American Academy of Pediatrics introduced the term in 1967), many point to 2008 as the year when the idea began to gel. That's when NCQA launched its patient-centered medical home recognition program, a status which serves as the industry seal of approval. The early iteration of the program required no EHR, but subsequent versions did, says Mina Harkins, assistant vice president, recognition programs, at Washington, D.C.-based NCQA. "Primary care is the focus, internal and family medicine," she says. "It's not for specialties. We are focused on a practice that is treating the whole person with both preventive care and chronic care."
To date, just over 4,900 group practices-encompassing 23,000 physicians, physician assistants and advanced nurse practitioners-have attained NCQA recognition as a medical home.
About 75 percent of the practices are at NCQA's Level III, the highest, and about 20 percent are at Level I, she says. To attain the highest level, practices must document their capability in a wide number of areas, including enhanced access for patients, use of evidence-based medicine, and tracking referrals. NCQA's scorecard for the recognition is a complex matrix (and requires renewal every three years). About 5 percent of applicants don't make the grade, Harkins says. "This is a lot of work," she acknowledges. "Most practices take it very seriously, but there are a few where the doctor told the manager to apply just for some health plan incentive and they don't pass."
The major primary care member associations, including the American Academy of Family Physicians and the American Academy of Pediatrics, have endorsed the model and offer their members tool-kits to help them revamp their operations and gain recognition, Harkins adds. While I.T. is only part of the package, Level III is designed to incorporate EHR meaningful use criteria, she says. "If you are using a certified EHR and attesting successfully, you've met about half the requirements," she says.
Attaining Level III status-a prerequisite for many payer incentive programs-is a time-consuming but critical exercise. For Family Medical Associates of Raleigh (N.C.), the impetus was that the state's Blue Cross Blue Shield plan tied medical home status to a new quality program that increased reimbursement, says Janet Spangler, practice administrator at the nine-provider group, which has already attested for Stage 1 meaningful use.
Spangler describes attaining the recognition as very difficult. "We spent three extremely intense months completing the documentation," she says. "The language NCQA uses for standards is up for a lot of interpretation. But as soon as you are stumped, they call you right back." The application process entailed sending proof of both capability and actual use. For example, to meet the mark on patient access, the practice had to provide both its access policy and a screen shot of its scheduling system showing the number of appointments left open for same-day access. "We sent 950 pages of documentation the first time," Spangler says, about half of which described policy and the other half showed I.T. capability. "Meaningful use is a piece of cake in comparison."
