Chapter 68: The Patient-Centered Medical Home

The 21st century began with some very exciting changes for primary care and specifically for family medicine. These changes are continuing to accelerate, heralding a bright future for the specialty. In this chapter we will discuss why a new model of primary care is essential; describe past, current, and future efforts for redesigning primary care with a focus on the patient-centered medical home (PCMH); and conclude with a discussion of how to transform both medical practices and the nation’s healthcare delivery system to take full advantage of the PCMH’s potential to improve the quality of, and access to, affordable care that enhances the well-being of everyone in this country.

The objective of any system of healthcare should be to improve the lives of the patients it serves, in terms of both the quality and the length of those lives, to create an environment in which people feel better, avoid preventable medical problems, ameliorate the effects of existing disease, and enjoy the lives they have as fully as possible.

Currently in the United States there are too many people who do not have adequate access to care, receive care that is of less than optimal quality, and obtain care that costs too much and has significant disparities in its provision (Institute of Medicine 2001). We need to do things differently because we know that there is a better way; a way that is based on solid scientific fact, which builds on the good of our current system and that is fair to all.

We must change from rewarding doing things to people, and create incentives to do things for people, from paying to do a task to paying for thinking about the task. Is a given procedure the most appropriate one for this individual at this particular time, if ever?

Past Attempts

A. Managed Care

In the early 1990s the idea of “managed care” was introduced into the United States, primarily as a way to increase profits and control costs by the insurance industry. This was popularly known as the “gatekeeper” system. Patients were required to visit a primary care provider (even though many subspecialists functioned in this role) who was approved by their insurance carrier to provide services under a particular plan as an entry point for any further access to the healthcare system. Payment was made to the physician on a capitated basis; that is, a fixed amount was paid to the physician for each member of that insurance plan who designated that individual as his or her primary care physician. The payment was the same each month regardless of whether the patient had been seen in that particular month. Additionally, a preauthorization was required for most services provided outside the physician’s office. Testing and procedures done in the physician’s office were rarely compensated beyond the amount of capitation. Understandably, both patients and physicians generally despised this idea.

It deprived the patient of freedom of choice, while increasing the inconvenience of obtaining a referral, test, or most any other service. Physicians were cast in the unfamiliar and uncomfortable role of being a patient adversary rather than a patient advocate. Payments were generally slow in coming and often did not come at all, making it difficult, if not impossible, for practices to maintain financial margins sufficient to maintain viability. This system was further flawed in that physicians were selected to be the “gatekeepers” solely on the condition that they have a pulse, and not by specialty or any other criterion that might indicate the physician’s ability to improve quality and control cost.

B. Case Management

Next, insurance companies and other third parties tried to charge employers and other insurance providers (such as state and federal governments) to provide chronic disease management services on the theory that managing the disease, and not the whole patient (without direct contact with the patient, by the way), would somehow improve the patient’s health and long-term prognosis. The only tangible results of this idea were to increase duplication of testing and increase the cost of providing insurance with no tangible benefit to anyone except the companies providing such services.

Present & Future

A. The Patient-Centered Medical Home

The term medical home originated in the 1960s with the American Academy of Pediatrics (AAP), who proposed that this entity be a repository for all medical information on certain patient populations. Since that time, the meaning and application of the concept of a medical home has varied. The idea has evolved to the patient-centered medical home (PCMH) as the framework for transforming healthcare in the United States.

Prior to the PCMH, there had been some progress toward conceptualizing a new model of care for chronic illnesses with the goal of improving clinical outcomes. The resulting chronic care model (CCM) (see Figure 68-1) was developed by Wagner and his colleagues at the MacColl Institute (Wagner 1998).

At the core of the CCM was a shift in focus from a reactive approach to a proactive one, resulting in improved outcomes through productive interactions between an informed and activated patient and a prepared and proactive practice team (ICIC 2008). The model posits that to improve the current healthcare system and promote high-quality chronic illness care, the system must be reorganized to include six essential elements. These elements include a health system that promotes safe, high-quality care by supporting effective and patient centered delivery system design, decision support, and self-management support strategies and clinical information systems as well as collaboration with the community to mobilize community resources to meet the needs of patients (IHI 2008).

Studies that incorporated one or more elements of the CCM provided extensive evidence to support the positive effects of CCM-based interventions on both clinical processes and patient outcomes (Glasgow et al. 2001; Ouwens et al. 2005; Tsai et al. 2005; Piatt et al. 2006) and cost-effectiveness (Bodenheimer et al. 2002). Each individual element of the CCM is important and can lead to improved outcomes. While no single element appears to be more effective than the other, the more CCM elements implemented, the better the outcomes (Tsai et al. 2005).

In the year 2000, leaders in family medicine assessed the specialty’s future role with the Future of Family Medicine Project (FFM), This effort, along with similar projects by the AAP and the American College of Physicians (ACP), ultimately became the second major step in development of the medical home.

During this period much independent research, both in the United States and abroad, demonstrated that primary care was associated with higher-quality care delivered at lower cost and with increased patient satisfaction. Simultaneously, IBM, aware of this research and its own experiential data from countries with primary care–based health systems, began to search for the same value in healthcare in the United States.

In spring 2006, having become aware of the now completed FFM project and its conclusion that the country’s family doctors physicians needed a “new model” of practice, representatives of IBM approached leaders of the American Academy of Family Physicians (AAFP) (Larry S. Fields, MD and Douglas Henley, MD) about collaboration on the issue.

Subsequently, the ACP and AAFP, along with IBM, convened a summit to educate and involve businesses, insurance companies, and physician groups such as the American Osteopathic Association (AOA) in the development and propagation of what came to be termed the patient-centered medical home (PCMH).

These groups developed and refined the principles on which the medical home would be based and formed the Patient-Centered Primary Care Collaborative (PCPCC) with headquarters in the nation’s capitol to promote and disseminate the medical home idea to businesses, the public, physicians, and insurance companies as well as to federal and state governments. Currently the PCPCC has over 700 member organizations representing 333,000 primary care physicians, several Fortune 500 companies and their millions of employees, major health insurance companies, governmental agencies, other physician groups, and organizations representing patients.

The PCMH has become the most important idea for health system change since the early 1960s. It is now the accepted vehicle to finally provide quality, affordable, accessible healthcare for everyone in the United States.

B. PCMH Evidence

Although the concept of a PCMH has been around for a while, the definition and framework are relatively new. Data demonstrating the effectiveness of PCMH care have been generated in various settings and various payment systems, including those composed of commercially insured, Medicare, Medicaid, and multipayer patient populations (PCPCC; “evidence for the PCMH” available at www.pcpcc.net). The evidence shows the PCMH’s positive effect on health outcomes, patient satisfaction, processes of care, and cost effectiveness (Glasgow et al. 2001; Tsai et al. 2005; Bodenheimer et al. 2002).

C. PCMH Benefits

The patient-centered medical home (PCMH) places patients and their interests at the center of the healthcare system. What is best for the patient is also best for the healthcare team and the system as a whole. “First, do what is right for the patient” should be the guiding principle in setting the priorities of the physician and other team members as well as the healthcare system.

The goal of the PCMH is for the patients to feel better, to have better health, to live longer and more productive lives, and to have access to less expensive services. Subspecialists can do what they are trained to do better than they do now. Hospital admissions and emergency department visits will decrease. In short, the PCMH is the only vehicle that can deliver high-quality healthcare at reasonable cost to every person in the United States.

The PCMH does not require inventing any new tests, treatments, or new specialties; it simply requires enough primary care physicians in the workforce, using the principles of the medical home, existing technology, and the best available evidence to do the “right thing” at the right time for the whole population.

Preventive services will be delivered more regularly, appropriately, and more broadly than currently. The lower the barriers to care (ie, copays) in the PCMH, the more patients will have an incentive to use its services rather than accessing the system at another, more expensive level.

The PCMH provides quality, accessible, cost-efficient healthcare that improves the health and well-being of people without depriving them of choice, riches, or independence.

Adherence to Accepted Standards & Recognition

The patient-centered medical home (PCMH), as defined by the National Committee for Quality Assurance (NCQA 2009), is a “healthcare setting that facilitates partnerships between individual patients, and their personal physicians, and when appropriate, the patient’s family. Care is facilitated by registries, information technology, health information exchange and other means to assure that patients get the indicated care when and where they need and want it in a culturally and linguistically appropriate manner.”

To describe the essential characteristics of the PCMH, the American Academy of Family Physicians, American Academy of Pediatrics, American College of Physicians, and the American Osteopathic Association (representing approximately 333,000 physicians) developed the Joint Principles of the Patient-Centered Medical Home, which are listed in Table 68-1.

The joint principles emphasize a patient-centered, holistic approach to patient care provided by a physician-led medical practice that should include collaboration with other disciplines such as nursing, pharmacy, nutrition, and behavioral science to meet the individual needs of the patients through integrated and/or coordinated care. No single individual can adequately meet all the needs of all the patients in a practice, thus teamwork and collaboration between disciplines in a manner that utilizes the strengths that each discipline brings to the team is essential to the success of the PCMH. The joint principles also emphasize enhanced access to care and an improved payment structure that combines enhanced fee for service as well as a per patient–per month payment or PPPM (see discussion below).

To be formally recognized as a PCMH, practices must meet a set of standards such as those established by the National Committee for Quality Assurance, URAC, The Joint Commission, or other certifying bodies that are aligned with the “Joint Principles” of the PCMH. Using this model, a practice would complete a self-assessment survey and submit documentation supporting the responses in the survey.

For practices interested in achieving PCMH status, TransforMED is an initiative of the AAFP to help practices get there by providing a framework and tools through online resources as well as direct consultation to facilitate necessary practice changes (Barclay 2006). The goal of a transformed practice is to improve quality, safety, and access while also increasing physician satisfaction [McGeeney, as cited in Barclay (2006)].

Individual Care Coordination

“I guess you know what’s happened to me since my last visit” or some variant thereof, is among the most dreaded phrases a patient can ever utter to a family physician. Dreadful because the physician immediately knows that several equally regrettable things have occurred. First, something the patient perceives as significant has taken place. Second, this event is likely to have been a nonspecific symptom (like chest pain) and involve several subspecialists, multiple tests (many of which may have been unnecessary if not redundant), and a whole lot of money. Third, and most dreadful of all, the physician has not the first clue as to what the patient is talking about.

It is clear from all available data that preventing this scenario is absolutely essential to controlling quality and cost. Regardless of whether an emergency department visit is avoided, or the number and type of tests a patient needs are more appropriately ordered, someone must be enabled to see that the care of a given individual is optimized. This function cannot be totally done in face-to-face encounters between patient and physician. Many types of “asynchronous” interactions will need to occur in order to achieve quality at acceptable cost. Delivering preventive services in the office; refilling prescriptions; educating patients about diet, exercise, and smoking cessation as well as making referrals; tracking consultations; handling abnormal test results; and a myriad of other tasks must be performed in a coordinated, well defined manner, or the game is lost.

The time and effort devoted to such asynchronous activities by all members of the healthcare team is labor-intensive and time-consuming. Properly performed, these endeavors will produce significant benefits to the health and well-being of individual patients, practices as a whole, and to society in general.

Care coordination is central to the success of the PCMH, as is integration of individual components of care into a unified plan and set of actions. To ensure a person’s health, there must be support and incentives, which are needed for practices to add these services and assume this responsibility. The mechanism to provide such support is a monthly payment to the medical professional (usually a primary care physician) responsible for the healthcare of a given individual in the PCMH. This monthly fee is additional to any payment made to the physician for services rendered when the patient is actually seen in the PCMH, hospital, nursing home, or other venue. The monthly payment continues as long as that patient is a member of that particular PCMH, regardless of whether the patient was seen in the PCMH in any given month. The payment must be adequate to sustain the PCMH’s fiscal ability to provide the range of asynchronous services required by its patients.

Monthly payments have been called many names, including per patient–per month payment (PPPM), case management fee, disease management fee, care coordination fee, pay for reporting, pay for performance, pay for use (ie, use of a qualified electronic health record), or simply “capitation” (which it is most definitely not). Such payments are better termed “care coordination and integration fees” (CIFs), so as to better describe their purpose.

A given practice will need to meet and maintain a rigorous set of standards like those of the National Committee for Quality Assurance (NCQA), which designates three levels that the PCMH might attain, each level having a correspondingly higher CIF.

Without the CIFs, the services mentioned above and the benefits to patients that derive from such services cannot be delivered on a consistent basis.

Reduction of Barriers to Care & Disparities in Care

Reducing financial barriers to receiving care in the PCMH is vital to the functioning of a successful PCMH. Concomitant system changes to enable the attainment of these goals are integral to providing fiscally stable entities that are ubiquitous enough to allow easy access.

Next, the amount paid on a fee-for-service basis for visits to the PCMH must increase significantly. Cognitive services, which make up the majority of services rendered by the PCMH, have long been undervalued relative to payments for procedures.

Along with reasonable CIFs, enhanced payments for services delivered by the PCMH have several positive results. The stability of the PCMH is considerably improved. As noted earlier, services provided by the PCMH would be enriched and be delivered in a more consistent manner. Because of the improved economics, more medical students will be able to choose primary care careers, thereby increasing the number of medical homes and improving access to those medical homes. Evidence tells us that increased access to primary care services will reduce—and may even eliminate—disparities that currently exist in healthcare.

How Do We Get There?

This question has implications for individual practices and the healthcare system as a whole. The answer is different for each. For individual practices, either large or small, the first step is the implementation of a functional electronic medical record (EMR) that has been certified as compliant with the standards for “meaningful use” (a governmental program supplying payments for practices implementing and appropriately using the certified EMR). Second, a thorough examination of the practice’s chosen certifying body’s standards for PCMH certification will provide a roadmap.

The EMR must provide functionality such as preventive care reminders, electronic prescribing, flagging of abnormal test results, performance data, referral tracking, and support for practice improvement initiatives. Written policies concerning patient access/communication and an interactive website will provide for higher levels of certification.

Changing the healthcare system to take advantage of the PCMH’s benefits is well under way. There are now over 17,000 certified medical homes.

The patient-centered medical home (PCMH) is an entity designed to build on the solid scientific evidence of quality and cost-effectiveness of primary care. It does not require inventing new technologies, nor does it require creating new kinds of physicians.

The PCMH will function in any environment, and under any payment system so long as the essentials of the medical home (strict adherence to the joint principles, individual care coordination, and reduction of barriers and disparities) are not compromised.

The PCMH is the mechanism that is transforming our healthcare system to achieve quality, affordable, accessible heathcare for everyone. This is too important for partisan politics and power grabs. This is about people, our friends, our families, and our fellow citizens. This is the time to look objectively at the facts and act accordingly. This is the time, and the PCMH is the vehicle, to finally bring longer, healthier, happier, and more productive lives to all of our people.