The Steal-A-Nurse-FTE Approach to the Patient Centered Medical Home

Quick: what’s better: renting it, buying it, borrowing it or just taking it? Of these four options, the last one – taking it – offers the best deal because you don’t have to offer up anything in exchange. Even borrowing involves trade offs, along with an expression of gratitude.

Which brings us to the Patient Centered Medical Home (PCMH). As the Disease Management Care Blog understands it, the PCMH is supposed to function as a one-stop primary care resource where grateful patients and unrushed providers can manage both prevention and illness in idyllic population-based tranquility. As first-among-equals, the physician presides over a happy band of nurses, educators, care managers and others, all thanks to an enlightened reimbursement mechanism supported by insurers, who in turn are soooo indebted to the docs for saving them oodles of money. That reimbursement typically will probably end up consisting of some combination of fee-for-service, a monthly fee, pay for performance and upside gainsharing.

Then why aren’t the physicians routinely assuming the cost of the nurses, educators and care managers? The DMCB checked out documents from the Southeast Pennsylvania learning collaborative (slide 16), Community Care of North Carolina (a poster child for the success of the medical home), the Rhode Island Chronic Care Sustainability Initiative (slide 11) for three examples of medical home models that rely on nurse care managers being salaried by entities other than the medical home practice itself. In reviewing some of the other pilots underway, the DMCB couldn’t quite tell which programs maintained local physician control of the nurses and which ones didn’t. It suspects there are a variety of approaches out there.

It’s an important issue. The DMCB is less concerned over the issue of nurse ‘loyalty’ being divided between the insurers or the physicians. Hire the right nurses, says the DMCB, and these savvy independent mission-driven providers can be counted on to do the right thing and maintain loyalty to the patients. No, says the DMCB, the reason it’s important is because the successful involvement of outside agencies in supplying personnel to local physician practices is perfectly aligned with an emerging disease management organization (DMO)-PCMH partnered business model. If IPIP, networks or insurers can hire the nurses, so can DMOs.

When it comes to the PCMH and nurse full time equivalents (FTEs), physician practices can 'build' (or buy a nurse and the other members of the health care team), rent (the DMCB predicts entrepreneurial nurses will offer local services at an hourly rate, such as visiting nurse agencies), borrow (even if there are no nurses left in primary care practices, can what are euphemistically referred to as ‘office assistants’ perform the task - thanks to a job description change?) or steal (i.e. take, let the holder of upstream insurance risk make some investment).

The DMCB likes the ‘steal’ model because it suspects many mainsteam small practice primary care physicians are not prepared to assemble, buy or rent all the components of a medical home team. The fact that they’re allowed to steal FTEs in some of the PCMH initiatives and pilots also speaks volumes about the potential of DMO-PCMH collaboration. The ‘steal model’ also increases the likelihood of scaling a standard PCMH benefit evenly across an insurance network. Finally, the DMCB predicts this may emerge as an important option in the upcoming Medicare Medical Home pilots.