HEALTH BENEFITS UPDATE
A look at the Patient Centered Medical Home model
This is the latest in my
series of articles addressing
the need to change health
care costs. The current governor has no concept of cost
savings, just cost shifting to
the employees. Perhaps this is
KEVIN C. due to his political allies, but
that being said, the labor side
LYONS
of the equation has been
researching exhaustively to come up with
concepts in health care that will deliver a
more efficient, and less costly, method of
health care.
Primarily, a health care provider’s main
responsibility is to produce health. Under
the current system, physicians are incentivized for seeing as many patients as they
can and addressing the issue at hand and
not the whole patient.
In other countries, primary care physicians outnumber specialists two to one, but
in the U.S. the opposite is true. One of the
main ways that we can change this pattern
and produce long-term health is to create
Patient Centered Medical Homes.
In this model, the primary care physicians
(PCP) are the centerpiece of the patient
healthcare. They can treat, manage and
coordinate the patient’s whole health. On
the average, a primary care physician is
incentivized to see as many patients as they
can in a scenario that is based on fee-for-service billing. This results in the PCP having
2,500-3,000 patients. Under the Patient Centered Medical Home model, this is
decreased to 1,000 patients and results in the
average face time growing from six minutes
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NEW JERSEY COPS
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MARCH 2015
in the current model to 22 minutes.
The way this is done is by putting physicians on salary and creating a network of
necessary medical services that are not associated with hospitals, which has clearly
become the monster that is eating our premiums.
Last month, the PBA signed on with all of
the other public sector labor unions to pilot
this concept within the State Health Benefits
Plan (SHBP) and the State Educational
Health Benefits Plan (SEHBP). Please understand that this is support of the investigation
of a concept; there is no agreement with
anyone that our members are “all in.”
The PBA has no intention of signing onto
a plan that will mandate membership in the
PCMH at this time. The pilot will contain up
to 60,000 SHBP/SEHBP members consisting
of two offices north and south of 10,000 each
and one central with 20,000 members (currently there are 895,000 lives between the
two plans). It will be for active members
only.
The incentive to enroll in the model will
be that members would have all co-pays
waived for the plan that they are in currently.
They will also be allowed to leave the pilot
program whenever they wish.
As I have stated before in front of the NJ
State PBA Board of Delegates, we have to be
innovative with regards to health care and
maintain, or even improve, the quality of the
care for our members. If we can keep our
members healthy, we will all save money
and live longer, which doesn’t seem like a
bad concept to me. d
A lesson in PBMs
Due to the continuing assault on our
members in the realm of Health Benefits,
Susan Hayes, the Principal in Pharmacy Outcomes Specialists in Illinois, a ce