Report from AMDA Long Term Care 2014 – Change, But No Clear Direction

March 18th, 2014 by Rod Baird

Dr. Len Gelman assumed the American Medical Directors Association’s Presidency at the annual meeting in Nashville, TN 2/22-3/2/14.

Dr. Gelman, takes the president’s role during a period of significant change in the long term care arena. He defined a theme focused on passion and conviction. Passion about what we do and conviction that what we do is right for the patients we collectively serve.

This event is the premier meeting for clinicians and their associates working in LTC; I and my colleagues were there in force. The meeting is where much of the coming year’s agenda for the LTC Physician community is developed, ideas exchanged and batteries recharged. During a 5 day period, I was fortunate to talk with hundreds of my colleagues, while manning our exhibit hall booth, co-presenting a talk on LTC quality management, attending committee meetings and simply being an audience member.

Unlike any of the other AMDA conferences I’ve attended over the past decade, this year everyone knows change is afoot. It was also equally apparent that there is no consensus about where we are headed, and often confusion about why. In other words, we pretty accurately reflected the state of America’s Medicare/Medicaid universe.

It’s taken me these 3 weeks to partially catch-up, sort-out, and reorder my own thoughts.

While Dr. Gelman continues a tradition of dedicated volunteer leadership, the sea-change in the AMDA administrative team is palpable and welcome. Chris Laxton, the Executive Director for the past 14 months is leading the staff and membership into areas previously unexplored. The topic with the most interest for me was the initiative to develop LTC specific quality measures. This includes both PQRS and eCQM use. It was gratifying seeing AMDA past Presidents Drs. Chuck Crecelius and Matt Wayne directing the efforts to bring members up to speed on what measures exist today, while also defining the future opportunity for measuring ‘collaborative quality measures’.

The magnitude of change is what also makes it difficult to chart a direction. In years past, AMDA had a steady mission – training physicians to be Nursing Home Medical Directors. Now the organization is expanding its horizons to help define models of LTC Practice.

How do providers practice in the LTC setting? There are multiple models – at least 4 by my count. Unless we define how we function, confusion can arise – nearly every physician, NP/APN, or PA who attends AMDA meetings has some direct patient care responsibility. But there are many models of practice. What is pertinent in one situation might be unrelated to another.

So, here are vignettes of my four provider models:

1. Facility Employed Staff – paid on basis of time, not volume; often with incentives included for productivity. Primary focus is on compliance and meeting facility quality benchmarks.
Employer may be public, not for profit, or private entity.

2. Domain Experts – Full time Medical Directors, Educators, etc. Focus is on managing the Care Process, not the specific encounter.

3. Community Based Providers – the numerical majority of AMDA membership. Serve patients in both an office and facility. Work in FFS or Managed Care oriented system, often with compensation related to productivity. Focus in on satisfying practice objectives for productivity or quality/outcome reporting. Ambulatory patient population isnumerically greater that LTPAC population.  Resources are largely focused on Office based services.

4. LT/PAC Only Physicians/Practices – usually physician led groups, although sometimes comprised of just a solo physician. There are also an increasing number of Nurse Practitioner groups, established to fill the gap between the availability of Community based attending physicians, and the facility’s perception of needed coverage. At AMDA these groups are usually represented by just a fraction of their provider numbers. Based on some data shared by a large facility chain’s CMO, the majority of all LTPAC medical services may be given by these multi-provider practices.

The type of practice that predominates is sensitive to location. Some areas are dominated by a particular model – it is very risky to generalize.

I’m enumerating various types of practices, not claiming the list to be universal, so we can begin understanding why it is so challenging to establish a sense of direction in these changing times. Each of these practice models are valid, but no one can claim to speak for all of them. Some of my subsequent blog posts will refer to one or more of these models of care. They are particularly important as LTPAC physicians begin to develop strategies for sharing quality measures and financial risk across the LTC continuum. Now that most of us agree change is afoot, let’s try to define the overarching themes.

Rod Baird

About Rod Baird

Rod Baird is the Founder and President of Geriatric Practice Management (GPM). Since 1977, he’s led provider and management organizations that deliver care to Medicare/Medicaid beneficiaries. Past programs he’s overseen include home health, personal care, hospice, rehabilitation hospitals, adult and psych daycare, alcohol/drug rehabilitation, industrial medicine and primary care practices. The Centers for Medicare and Medicaid Services (CMS) selected Baird as one of only 73 individuals to serve with its InnovationProgram. His educational background includes a Master’s Degree in Physical Chemistry from the American University, Washington, D.C.

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