Moving to a PCMH Model
In theory, all providers would say they offer patient-centered care. In practice, however, there is often a disconnect when it comes to how care is actually delivered in the United States.
Who’s On Board
The core team pushing for the broad adoption of a PCMH model has been the four major primary care organizations: American Academy of Pediatrics, American Academy of Family Physicians, American College of Physicians, and the American Osteopathic Association. They are joined by 19 other national organizations who support the principles of the medical home model, including:
- American Academy of Hospice and Palliative Medicine
- American Academy of Neurology
- American College of Cardiology
- American College of Chest Physicians
- American College of Osteopathic Family Physicians
- American College of Osteopathic Internists
- American Geriatrics Society
- American Medical Association
- American Medical Directors Association
- American Society of Addiction Medicine
- American Society of Clinical Oncology
- Association of Professors of Medicine
- Association of Program Directors in Internal Medicine
- Clerkship Directors in Internal Medicine
- Infectious Diseases Society of America
- Society for Adolescent Medicine
- Society of Critical Care Medicine
- Society of General Internal Medicine
- The Endocrine Society
In addition, the Patient-Centered Primary Care Collaborative (PCPCC) is a coalition of more than 260 patient advocate groups, major employers, health plans, and physician membership organizations that have joined to advance the patient-centered medical home.
Outside forces ranging from a culture of practicing medicine in silos to incompatible technology across provider platforms to a reimbursement system based on volume rather than outcomes all impact the reality of day-to-day operations. Increasingly, practitioners are expressing a desire to change the status quo and engage patients, caregivers, and colleagues in a different model of care.
The Patient-Centered Medical Home (PCMH) is a team-based care model led by a personal physician who provides continuous and coordinated care throughout a patient’s lifetime to maximize health outcomes.
The American Academy of Pediatrics (AAP) first introduced the term “medical home” in the 1960s. In 1992, the AAP formally defined it as a model of comprehensive, coordinated care for children with special needs. Ed Wagner, MD, MPH, FACP, director of the MacColl Institute for Healthcare Innovation is generally credited with adapting the model for those with chronic illness. By the early 2000s, family medicine picked up on the concept, and in January 2006, the American College of Physicians (ACP) released a policy paper, “The Advanced Medical Home: A Patient-Centered, Physician-Guided Model of Health Care,” building upon the earlier chronic care model.
Michael S. Barr, MD, MBA, FACP, senior vice president of Medical Practice, Professionalism and Quality for the ACP, explained the thought behind expanding the patient population included in the care model was that everyone has special needs at one time or another, and all could benefit from coordinated care. At the same time, Barr continued, the ACP recognized the model could not exist in the current fee-for-service environment since providers wouldn’t be reimbursed for many of the activities and attributes of PCMH.
“In some regards, it is taking old-fashioned medicine and putting it into the future,” Barr said. “It’s reinvigorating that physician-patient relationship and putting the patient at the center of the team. Patients get lost in the morass of healthcare silos. What PCMH does is break down those silos.”
Barr, who works out of the ACP’s Washington, D.C. office, noted what really accelerated the interest in PCMH was when large employers began to take notice of the concept in the spring of 2006, led initially by IBM Corporation’s Global Director Paul Grundy MD, MPH, FACOEM. In a meeting with Barr, Grundy said the kind of care being described by the ACP was what his company could purchase for employees everywhere in the world except in the United States.
IBM helped pull together some of the country’s largest employers to learn more about the care model and to call for demonstration projects. Barr noted the PCMH concept got a boost with the 2006 Tax Relief & Health Care Act. “In that was the first mention, that we know of, testing the medical home in the Medicare population. There was now legislation within one year of releasing the paper.”
Barr noted the project was never implemented because the healthcare reform movement began shortly thereafter. However, he continued, the Affordable Care Act contains the medical home concept as part of the Comprehensive Primary Care Initiative launched last year. Interestingly, Barr said early on most people looked at PCMH and Accountable Care Organizations (ACOs), the other model gaining traction right now, as an ‘either/or’ proposition. “Now we talk about ‘both.’ An ACO must have a foundation of primary care.”
Barr said the PCMH model not only focuses on quality and safety but also looks at cost. ACP launched the High Value, Cost-Conscious Care Initiative in April 2010 to address unnecessary costs to the healthcare system.
“We’re not talking about rationing, but we’re talking about the appropriate use of our tests, imaging, prescriptions, and so on, to provide the best care.”
He added that it’s more than just addressing the practice of defensive medicine but also eliminating unnecessary duplication and putting the brakes on ordering tests or medications as the path of least resistance. “In the fast-paced world that many physicians work in, the time it takes to sit down and counsel why you don’t need something is counterproductive when you have to see so many patients, and patients are stacking up in the waiting room. The fee-for-service environment fosters that.” Barr added he wasn’t condoning such practices but said it was often the reality.
Barr noted that when assessing costs in the PCMH model, it’s important to take the long view. In the short run, he said, some costs could actually increase for employers and payers. For example, he pointed out, prescription costs could increase if a patient is more aggressively treated for diabetes; but down the line, costs associated with missed work, lowered productivity, amputations and increased mortality are decreased or avoided.
Besides, he pointed out, “People have a hard time arguing with you that we shouldn’t offer patient-centered medical care.”
Mark Your Calendars
For those interested in learning more about the PCMH concepts, the Patient-Centered Primary Care Collaborative is holding its Spring Stakeholder’s Conference April 23-24 in Washington, DC. For details, go online to www.pcpcc.net.
Also, the American College of Physicians has created an online learning tool, Medical Home Builder®, with modules covering all aspects of creating a sustainable patient-centered practice. There are two live demonstration webinars coming up on April 11 and April 24. While the demonstration webinar is free, participants must register. Go online to www.acponline.org/running_practice/pcmh/help.htm.
Still, he recognizes the pressure physicians and other providers face with new rules, ideas and regulations. “There’s a lot of stuff going on in the environment, and we’re asking them to fundamentally change the way they practice,” Barr acknowledged.
In the end, however, the belief is that patients and providers wind up with a true healthcare … as opposed to the current sick care … system with higher quality, greater satisfaction and reduced overall costs.