How to change PCP - Points to consider

Changing Primary Care Providers

Tufts Medicare Preferred HMO members or their authorized representatives may request to change their selected PCP to a PCP within the Tufts Medicare Preferred HMO service area. Tufts Health Plan must receive the member’s request either by phone or in writing by 4 p.m. of the last business day of the month for the transfer to be effective the first day of the following month. Transfers are normally effective on the first day of the following month. Tufts Medicare Preferred HMO providers should make efforts to ensure that the member’s records are transferred to the new PCP in a timely manner to ensure continuity of care.

Each Tufts Medicare Preferred HMO member selects a PCP and at times during this physician/ patient relationship situations arise where the PCP and member do not agree. These disagreements can usually be discussed to develop an action plan agreed upon by both parties. For instance members may disagree with the PCP suggested treatments or may opt for no treatment for some medical issues. These issues usually do not cause alarm or grave concern for the member’s health.
In some cases members select PCPs but choose not to participate in annual visits. This is the member’s choice and cannot be a reason to discharge a member from a PCP panel. At any time please notify your care manager to reach out to member to learn if there are barriers that may be preventing the member from visiting the PCP office. Transportation services or nurse practitioner home visits should be considered.

In rare circumstances, a member’s behavior may interfere with the member’s treatment plan initiated by the PCP. In these circumstances the PCP must discuss his/her concerns with the member and document in the member’s medical record. If the member’s behavior continues to interfere with the treatment plan, the PCP may issue a notice to the member documenting their discussion and actions agreed upon. This notice is titled Non-Compliance of Physician Treatment Plan. This notice describes the situations in which the member’s behavior has impaired the physician’s ability to furnish services and for which the PCP has given the member opportunity to explain his or her behavior. After the notice has been issued, this notice may be issued a second time if the member has not taken action to correct the non-compliance issue. If the non-compliance of treatment persists despite discussions with the member and sending two written notices, both parties may come to an agreement that the member would best be served by arranging to change their PCP. If the member has not taken action to change his/her behavior and does not want to change his/her PCP, the PCP should contact Provider



Relations for assistance with ongoing management of the member’s care. The PCP may not discharge a Tufts Medicare Preferred HMO member. The member may voluntarily make a PCP change.

In extremely rare circumstances, inappropriate disruptive behavior on the part of the member may exist impairing the ability of the provider to furnish quality medical services. A PCP is expected to contact the health plan when they feel a member has displayed true disruptive behavior. This disruptive behavior is behavior that will substantially impair the PCP’s ability to arrange for or provide services to either that particular member or other members of the plan. In these cases of behavioral concern, the PCP must discuss the case with the health plan that will investigate the case details and determine if further actions up to and including requesting disenrollment will be initiated. In the event you believe you have a disruptive member, contact Provider Relations and notify your care manager.

Notes



Tufts Health Plan requires the following from the Tufts Medicare Preferred HMO PCP:

** Documentation that the Tufts Medicare Preferred HMO provider has discussed with the member (or authorized representative) the issues that are affecting the member’s medical treatment

** The PCP must send the Non-Compliance of Physician Treatment Plan letter(s) to the member, with copies to the Tufts Health Plan Medicare Preferred Provider Relations Department for the member’s file.

The letter must provide specific description of the concern with specific physician orders, dates of non-compliance and physician recommendations.

Examples of when PCPs may use this letter include situations such as when the member’s treatment plan involves appointments with the PCP every other week to evaluate a wound status and wound care regimen, but the member has failed to keep the last two appointments although the PCP’s office staff has called in advance to remind the member of each appointment.

The notice should include how the member could comply with the treatment plan and should be sent to the member on two separate occasions, allowing a reasonable time for the member to demonstrate compliance with the treatment plan.

Who is PCP and responsibility of PCP

Primary Care Providers

Primary care providers (PCPs) are responsible for monitoring the care of their Tufts Medicare Preferred HMO members to provide quality and cost-efficient medical management.

The PCP must be able to provide integrated, accessible health care services and be accountable for addressing a large majority of personal health needs, developing a sustained partnership with members, and practicing in the context of the family and community.
The following list encompasses a common set of proficiencies for all PCPs:

? Training in a primary care discipline, or significant additional training in primary care subsequent to training in a non-primary care discipline

? Periodic assessment of the asymptomatic patient

? Screening for early disease detection

? Evaluation and management of acute illness

? Ongoing management of members with established chronic diseases

? Coordination of care among specialists, including acute hospital care and long-term care

? Assessment and either management or referral of members with more complex problems requiring the diagnostic and therapeutic tools of a specialist or other health care professional.


Note: Any provider designated as a PCP must devote a significant percent of his/her clinical time in a practice that encompasses the above list of proficiencies. This list is adapted from the Report on Primary Care from the Institute of Medicine, 1996.




Responsibilities

PCPs are responsible for providing or arranging the total care of their Tufts Medicare Preferred HMO members. This includes providing high-quality, cost-efficient medical care and/or management. The PCP’s role in successfully recognizing and addressing the member’s needs is key to the success and satisfaction of the member, the medical group and Tufts Medicare Preferred HMOPCP responsibilities include the following:

? Providing care in a manner consistent with recognized standards of health care and in a culturally-competent manner to all Tufts Medicare Preferred HMO members, including those with limited English proficiency or reading skills, diverse cultural and ethnic backgrounds and physical or mental disabilities. Successful medical service management and coordination ensures continuity of care and eliminates test and procedure duplication.

? Being accessible to members 24 hours a day, 7 days a week via direct contact or through PCP-arranged provider alternative, another Tufts Medicare Preferred HMO participating provider.

? Coordinating services that allow for continuity of care and integration of services, including:



Continuous patient care and quality review

An initial assessment of the member’s health care needs within 90 days of the member’s initial enrollment Systems to address barriers to the member’s compliance with the physician’s prescribed treatments or regimens Procedures to ensure that members are informed by providers of specific health care needs that require follow-up care and receive care/treatment as appropriate Training in self-care and other measures that members should take to promote their health.

? Arranging for the continuation of benefits in the event of plan contract termination, non-renewal, or insolvency through the end of the period for which the Tufts Medicare Preferred HMO member’s premium is paid or hospital discharge date by the following:



Honoring all open authorizations for care

Placing outbound calls to affected Tufts Medicare Preferred HMO members who are scheduled for services and undergoing treatment plans to coordinate continuation of care

Providing an opportunity for members undergoing a treatment plan to continue to see providers who are no longer in the  etwork due to the group insolvency