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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.
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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.
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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.
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A. The Patient-Centered Medical Home
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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.
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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).
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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).
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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).
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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.
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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.
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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.
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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).
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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.
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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.
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American Academy of Family Physicians. The New Model of Primary Care: Knowledge Bought Dearly. AAFP; 2004 (retrieved July 16, 2009).
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Glasgow
RE, Hiss
RG, Anderson
RM
et al.. Report of the Health Care Delivery Work Group: behavioral research related to the establishment of a chronic disease model for diabetes care. Diabetes Care. 2001;24(1):124–130.
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Ouwens
M, Wollersheim
H
et al.. Integrated care programmes for chronically ill patients: a review of systematic reviews. Int J Qual Health Care. 2005;17(2):141–146.
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Piatt
GA
et al.. Translating the Chronic Care Model into the community. Diabetes Care. 2006;29(4):811–817.
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Robert Graham Center. The Patient Centered Medical Home: History, Seven Core Features, Evidence and Transformational Change. American Academy of Family Physicians; 2007.
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Tsai
A, Morton
S, Mangione
C, Keeler
E. A meta-analysis of interventions to improve chronic illness Care Am J Manage Care. 2005;11:478–488.
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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).
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Glasgow
RE, Hiss
RG, Anderson
RM
et al.. Report of the Health Care Delivery Work Group: behavioral research related to the establishment of a chronic disease model for diabetes care. Diabetes Care. 2001;24(1):124–130.
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Stewart
E
et al.. Preliminary Answers to Policy-Relevant Questions: From the Early Analyses of the Independent Evaluation Team of the National Demonstration Project of TransforMED (retrieved July 9, 2009).
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Patient Centered Primary Care Collaborative. The Outcomes of Implementing Patient-Centered Medical Home Interventions: A Review of the Evidence on Quality, Access and Costs from Recent Prospective Evaluation Sstudies. PCPCC; 2009. (Prepared by Kevin Grumbach, MD; Thomas Bodenheimer, MD, MPH; and Paul Grundy MD, MPH. Retrieved Aug. 20, 2010).
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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.
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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.
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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.
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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.
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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.