7/30/13

Doctors and Lawyers Part II: The Patient Centered Medical Home

 (This is part 2 of a 4 part series. You can download the entire series here.)

In the midst of the very same economic turmoil that set Law Firms spinning in 2007, a number of medical care professional organizations came together to craft the Patient Centered Medical Home (PCMH).  The PCMH is part manifesto, part best-practice guidelines, designed to put patients at the center of their own medical care. I believe the use of the word "home" in this case muddles the meaning, but it's intended to be less off-putting and more inviting to patients than the words "Medical Practice".  The PCMH model, is an attempt to re-engineer the practice of medicine from the unholy mess that naturally evolved between the interactions of hospitals, doctors, government agencies, and insurance companies in the late 20th century, into an efficient 21st century medical care machine, with patient well-being as its primary focus.

There are four areas that the PCMH addresses:

Team-based Primary Care is about doctors sharing the responsibility for patient primary care with "nurses, care coordinators, patient educators, clinical pharmacists, social workers, behavioral health specialists, and other team members."(1)  Historically, doctors have been very proprietary with patient access, refusing to allow other doctors, or especially non-doctors, to treat their patients. In a PCMH, data and records are openly shared (within appropriate regulatory guidelines) and primary patient care is a group effort.

Active Patient Involvement is making patients active participants in their medical care, rather than passive recipients of treatment.  This requires the help of the larger team to educate and work with the patient to arrive at the best course of action.

Evidence-based Practice Improvement means applying the scientific method to common medical procedures, which sounds obvious, but has not always been the case.  Doctors often believe that the way they have always done something is the best way to do it.  Practice improvement challenges the status-quo by testing and confirming best practices with actual data rather than anecdotal evidence.

And finally, Payment Reform is restructuring the way that doctors and insurance companies are paid to align the financial incentives in the medical industry with the needs of the patient, instead of the needs of the medical practitioners or insurance companies.

This sounds great, but the value is not in defining the areas that need reform, but in actually creating a clear path to get there.  There is a regulatory component to the PCMH that is administered by a non-profit organization called the National Committee for Quality Assurance (NCQA).

NCQA has established clear guidelines for any medical practice to qualify as a PCMH.  They've broken the guidelines down into 6 distinct Standards which each include between 2 and 7 individually scored elements and a single Must-Pass Element. The Must-Pass Elements are:
1) Access During Office Hours;
2) Use Data for Population Management;
3) Care Management;
4) Support Self-Care Process;
5) Referral Tracking and Follow-Up; and
6) Implement Continuous Quality Improvement.
These 6 Must-Pass Elements are things that any competent medical practice should already be doing.

Barely squeaking by on the 6 Must-Pass Elements will give a PCMH applicant a minimum score of 15 out of 100.  If they can cobble together another 20 points out of all of the other elements to get a score of 35 out of 100, they will qualify as a Level 1 PCMH.  Level 2 requires the 6 Must-Pass and a score of 60; Level 3 the 6 Must-Pass and a score of 85.  The value of this system is that the barriers to Level 1 PCMH qualification are truly minimal.  Most organizations should already meet Level 1 requirements, or should meet them with a very few enhancements to their practice. At the same time the Standards and Elements provide a clear road map to improve patient centered care and to eventually reach a Level 3 certification, which is much more comprehensive and difficult to achieve. A Level 3 PCMH is a truly exemplary practice in which Doctors, Staff, and Hospitals work together seamlessly to provide the best possible care to a very well-informed and participatory patient.

Why can't the same concept work for legal?  As established in the last post, we have very similar problems, and very similar needs.  Of course the details are different, but we could easily have a non-profit regulatory organization that certifies law firms as Level 1, 2, or 3 Client Centered Legal Practices.

In the next installment, I'll explore what a CCLP might look like.

PS. I've published a short post on this same topic at the Lexis Future of Law blog. (Not my title.)

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