Dr. Xavier Sevilla, practicing pediatrician and the Academy of Pediatrics representative to NCQA's Advisory Panel on the patient-centered medical home, walks us through the experience of building a medical home from the ground-up. From staffing to record-keeping, he considers the components that have helped him to develop a pediatric practice with the elements of a medical home. How can you use his experience to shape your practice? Hosted by Dr. Larry Kaskel.
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Building a Medical Home From the Ground Up
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HOW TO CONVERT TRADITIONAL MEDICAL PRACTICE INTO MEDICAL HOME
Concept of Medical home has evolved since its introduction by the American Academy of Pediatrics in 1967. It is gone from a specific place to receive care for children with chronic disease to an entire system of providing care for all Americans. Let’s see if we can learn how to convert our own practice to a medical home.
Welcome to the Clinician’s Roundtable. I am your host Dr. Larry Kaskel joining me today is Dr. Xavier Sevilla, Chief of Pediatrics at Whole Child Pediatrics and the American Academy Pediatrics representative through the National Committee for Quality Assurance.
DR. LARRY KASKEL:
Dr. Sevilla, welcome to the show.
DR. XAVIER SEVILLA:
Glad to be here Larry.
DR. LARRY KASKEL:
Can you start by telling our audience what really the key concepts are that define a practice as a medical home?
DR. XAVIER SEVILLA:
The key attributes to a medical home are a practice that has superb access to care that offers a continuous relationship between the doctor and the family. The practice that coordinates care both during the visit, after the visit, and before the visit. A practice that has family for patient’s centered care and the practice that really covers all comprehensive parts of health, so acute health, chronic illness, preventative health, and that covers really all the global areas of healthcare.
DR. LARRY KASKEL:
And Dr. Sevilla would you mind sharing your personal journey that really inspired you to kind of rethink what you are doing and transition over to a medical home?
DR. XAVIER SEVILLA:
Well, I was working in an office that had 5 pediatricians and 1 nurse practitioner, a very busy office, pretty much structured like any other pediatric office was and at the same time, I got involved with the American Academy of Pediatrics in terms of their medical home effort. Soon as I looked at the attributes of the medical home and how this would be integrated into one package as the medical home, I was very much attracted to that idea and I really realized that that’s the way that I wanted to practice in the future. So, in November of 2007, I decided to go ahead and open a practice that would start from day 0 with those components and elements that make a medical home and that’s been the journey that I have had since then.
DR. LARRY KASKEL:
Did you leave your existing practice or did you take what you had and adapted?
DR. XAVIER SEVILLA:
I started a completely new practice in a different part of town. I did have a few of my patients from my other practice follow me, but we really started with a blank slate where we could really design what we wanted, everything even from the design of the building to the staffing was really already looking at what we wanted to do in terms of the medical home.
DR. LARRY KASKEL:
Then, you must have had some deep pockets behind you or some seed money to allow you to do that or you are independently wealthy?
DR. XAVIER SEVILLA:
I don’t know about the deep pockets. I actually did this kind of in a partnership with the Community Health Center that I was working at before and I provided the office. I designed the office. I gave the practice of philosophy and they provide me with the billing, the human resources, and it's worked out very well perhaps to adapt. In that way, I really didn’t have to be a millionaire or have a very rich uncle.
DR. LARRY KASKEL:
Did you have to get new staff, because I could see how old staff were just kind of brainwashed to the old style and resistant to change?
DR. XAVIER SEVILLA:
You know, Larry that’s a really interesting question and my original idea was to start from zero, new staff, new building, and a new philosophy because of the same reason that you just mentioned. Now for unforeseen circumstances this did not happen. I had to actually work with staff that I had in the other office and I wondered if this was going to work, if the new system was going to be able to be transferred to this building if I had the same type of staff. Now one of the things about the medical home that I have discovered and this is I think with any practice, doesn’t have to be a medical home, is really the relationship inside the practice. The quality of those relationships inside the practice are actually more important that the quality of the people working in the practice and this has been corroborated by the project conformed from the American Academy of Family Physicians, and they have actually found the quality of the staff is not as important as the relationship and the internal web of relationships inside the practice. So, in terms of our practice, we have been able to work this together and our medical home has worked even though the fact that I have was actually used to a different system, but we have been able to accommodate it by having a good collaborated culture inside the office.
DR. LARRY KASKEL:
If you have just tuned in you are listening to the Clinician’s Roundtable. I am your host, Dr. Larry Kaskel and I am talking to Dr. Xavier Sevilla, Chief of Pediatrics at Whole Child Pediatrics in Lakewood Ranch, Florida, and we are talking about how to convert a traditional medical practice into a medical home.
Dr. Sevilla, you were talking about the relationships of the employees and I really think that any small practice, the tone that the leader sets is really followed throughout the whole staff and you can walk into different offices in the same medical building and you can immediately feel that tone that is set.
DR. XAVIER SEVILLA:
I couldn’t agree more Larry and this was something that I want to stress the people listen to this program that a lot of people are thinking well the medical home is very high-tech with new high-tech staff and that’s not really the case. The high-tech staff may be able to support you, you know, and what I am talking about hi tech, I am talking about the electronic medical record, the electronic registry. They may be able to support what you do, but really this is still high-type medicine as opposed to high-tech medicine and seems like the relationships inside the practice, the other parts that I would say is probably one of the most critical parts of the medical home is patient centeredness and that is something that really is a transformation for our physicians to go from a really physician centered type of care to a patient centered care. So, I really feel that most of the things need to occur before people actually even think about going into a medical home, and only then once you have the issues that we talked about is when you will be very successful putting one together.
DR. LARRY KASKEL:
It also sounds to me that you really need to have the right personality to be actually a loving physician to even be successful at having this type of home. It really requires your personality to make it work.
DR. XAVIER SEVILLA:
I totally agree Larry and I talk to lots of primary care physicians, very hard working people who are at the moment very dissatisfied with their job and with their profession and part of that I believe is that we have taken the relationship part out of medicine and we have made it into, you know, a conveyor belt.
DR. LARRY KASKEL:
Right, a commodity-based business.
DR. XAVIER SEVILLA:
It is and once you put back to relationship, you know there is just no way I would go back to the old way of practice. I mean, there is just no way. It is just so much more satisfying as a doctor to have that relationship again with your patient's, you know, and the patients like it too. They really miss that from the current medical system. So, I think really it’s a win-win for patients and doctors.
DR. LARRY KASKEL:
Sevilla, I live in a pretty affluent suburb and many of the physicians have gone <_____> in my area and it sounds like you have a similar concept that you are really providing excellent care, you are not charging more, but you are providing more care, so do you actually take a hit in income for the trait of in quality of your practice in your life?
DR. XAVIER SEVILLA:
The current payment system does not support this. You are absolutely right. If the current system supports more volume, more intensity if you want to make more money. I mean that’s the bottom line. I don’t necessarily think that by being a medical home, you need certainly have to drop your volume, but with the current level of reimbursement of just purely episodic visits being reimbursed. I think it’s going to be hard to expect your income to go up with this model. Now when the payment environment changes, and I say when instead of if because I think it is going to change. I think it is going to be more supportive of this. Then I think, it is a very good challenge for us primary care doctors to add CC and increase in our income when you practice this way.
DR. LARRY KASKEL:
Sevilla, you mentioned that all of the leading primary care physician organizations have kind of gotten together to create a joint principal of patient-centered medical homes and so it seems now that they really need to start lobbing the insurance companies to convince them that this is a viable concept and make sense for them.
DR. XAVIER SEVILLA:
Absolutely right and I think the key here are two key alai for us of the professional organizations and one is the employer. As I mentioned before, the employers are behind this because I am going to use the quote. They don’t want to pay for the junk that they are getting right now and this is a quote from someone from the Elisa Group. So, they have realized that their double digit increases every year on health premiums are not buying quality health care and they really want this to change and so I think they are really a big driver behind this and I think they are the only ones that really have the power to make the insurance companies change. The other big alai is our patients, so I think consumer organizations, patient organizations have been clamoring for the medical home for a more patient-centered or family-centered way to practice medicine, and I think if we get them on our side, we are going to be a very good agent for change that I think in the end it is going to benefit us, primary care doctors.
DR. LARRY KASKEL:
Sevilla, if someone out there is listening in terrestrial or extraterrestrial radio, how can they go about doing this conversion? Did you use a template or a checklist? Did you have a consultant helped you?
DR. XAVIER SEVILLA:
A friend of mine from Louisiana says lots of ways to make gamble. So, there is not one way to become a medical home. There are lots of different practices out there that have different components of the medical home. Now, there is a recognition program right now that is being offered by NCQA where you can actually be recognized as a patient-centered medical home and this is an instrument where you basically have to self audit your practice and see if some of the elements are out there and NCQA will again check, and if that is the case, they will give you that recognition. Now, this is probably what most insurance companies are going to use to see, who really is in medical home or not, but there is also definitely a lot of information on the medical home from the professional societies. So, from the Academy of Pediatrics, we have a website called medicalhomeimprovement.org. The AASP and the ACP have their own health pages in the website that can give their members information about how to go about becoming a medical home.
DR. LARRY KASKEL:
Dr. Xavier Sevilla, thank you so much for talking with me today and I wish you the best in making your medical home model a reality.
DR. XAVIER SEVILLA:
Thank you so much Larry. It was very nice talking to you.
DR. LARRY KASKEL:
I am Dr. Larry Kaskel. You have been listening to the Clinician’s Roundtable on ReachMD XM. To comment or listen to our full library of on-demand podcasts, please visit our website at reachmd.com and thanks for listening.
You are listening to ReachMD XM 160, The Channel for Medical Professionals.
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Dr. Xavier Sevilla, practicing pediatrician and the Academy of Pediatrics representative to NCQA's Advisory Panel on the patient-centered medical home, walks us through the experience of building a medical home from the ground-up. From staffing to record-keeping, he considers the components that have helped him to develop a pediatric practice with the elements of a medical home. How can you use his experience to shape your practice? Hosted by Dr. Larry Kaskel.
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