A lot of people look at a specialist as a technician… I believe that technology has taken us away from the patient’s story. And once you remove yourself from the patient’s story you no longer are truly a doctor. -Myron Falchuk, MD, in How Doctors Think by Jerome Groopman, MD
If primary care physicians are to be believed, home is where the patient is-the Patient-Centered Medical Home (PC-MH), that is. The combined 333,000 members of the American College of Physicians (ACP), American Academy of Pediatrics (AAP), American Academy of Family Physicians (AAFP), and American Osteopathic Association (AOA) have closed ranks behind the medical home-a practice-based model anchored on a personal physician providing and coordinating health care for his or her pediatric or adult patients. PC-MH proponents argue that medicine’s dwindling cadre of generalists is reimbursed inadequately-or not at all-for coordination and tracking of care, adding that pay-for-performance schemes won’t help because they boost revenue incrementally rather than changing a fundamentally flawed reimbursement system. The PC-MH is designed to address all that.
PC-MH’s core assumption is that primary care physicians (PCPs) coordinating care across settings will improve health outcomes and lower costs. The concept being promoted currently puts tools including care coordination, care management, health information technology, patient education, and access to 24/7 coverage into PCPs’ hands (see sidebar, Practice Readiness for the Medical Home).
Michael Barr, MD, MBA, the American College of Physicians’ Vice President for Practice Advocacy and Improvement, explained that the medical home is very complex, and we’ve got aggressive timelines to its implementation. The step-by-step blueprint to patient-centered care can help even a one- or two-person medical practice accomplish elements of the medical home.
In describing how it would affect specialists, Dr. Barr eschewed any similarity between the medical home and gatekeeping. The medical home doesn’t involve global capitation, which rewards PCPs for not referring to specialists. Instead, it builds on FFS [fee-for-service] and rewards enhanced primary care performance. It will benefit specialists because referrals will be tracked improved, and information between PCP and specialists will be better organized through computer technology, said Dr. Barr.
Otolaryngologist Howard Hessan, MD, a solo practitioner in Ellicott City, MD, who works with many PCPs, said the PC-MH concept sounds interesting and desirable. With reimbursement pressures, PCPs have no time to spend with their patients. Sometimes they refer to an ENT or other specialist when they can do the work themselves just because they have no time. That is not proper care. Better reimbursement for PCPs will be great for everyone, he said.
Dr. Hessan already has experience with a PC-MH prototype. He receives many referrals from Erickson Retirement Communities’ medical group at its Charlestown campus, and sees patients there one-half day each month. Erickson has an EMR [electronic medical record] and the doctors have 30-minute patient visits. They’re great sounding boards for insight into our patients.
One medical home gray area is who will treat routine otolaryngological diagnoses such as sinusitis. A PCP who now refers sinusitis cases to an otolaryngologist due to time pressure would have more time under the PC-MH to see those patients.
William Reichel, MD, retired department chairman of Baltimore’s Franklin Square Hospital family medicine program, said, I believe primary care is having a hard time now, so the medical home is an appealing answer to the importance of the primary care physician remaining as the central coordinator in patient care. He continued, The medical home will pay for the coordinator role and continuity as patients go from cardiologist to orthopedist to otolaryngologist. Hopefully, the PCP will not be a gatekeeper directing traffic according to rules set down by the payer, but a filter and coordinator of referrals.
Allan Khoury, MD, an internist and Chief Medical Officer of Whole Health Management, which provides onsite corporate health care, sees the medical home’s emphasis on information technology (IT) as critical to success. The baskets of care delivered by doctors aren’t connected. If a patient presents with a sore knee, we should know that he had angioplasty seven years ago and has high cholesterol, for possible links to current symptoms. The PC-MH will reduce medical errors and specialists will benefit because of better documentation and coordination by the personal physician. He added, Also important is that the PC-MH will not put specialists at financial risk.
Show Us the Money
Corporations and major health plans with deep pockets strongly support the medical home concept. Like physicians, they’re rallying around this radical attempt to fix a broken system. A coalition of prominent insurers-Aetna, Blue Cross, Cigna, Humana, MVP Health, United Healthcare, and Wellpoint-and large employers spearheaded by IBM, called the Patient-Centered Primary Care Collaborative (www.PCPCC.net ), is funding demonstration projects and providing consultants to state governments willing to implement PC-MH projects.
Joe Grundy, PCPCC’s press liaison, explained that the group’s significant membership dues fund experts, consultants, working groups, and a PC-MH summit. Additionally, the Portland, ME-based National Academy for State Health Policy is using a $150,000 grant to help teams from 10 states implement Medicaid PC-MHs, also gathering data on common issues and obstacles. The AAFP, with TransforMED, its practice redesign arm, gave $8 million for launching PC-MH demonstration projects, with another $4 million to extend efforts for two years.
Show Us the Demos
Without evidence that the medical home’s higher spending on primary care will save money down the road, the concept may collapse under the weight of good intentions. Nevertheless, the New York-based Commonwealth Fund projects $60 billion cumulative savings in national health expenditures over five years and $193.5 billion over 10 years if Medicare FFS beneficiaries are required to enroll in a medical home. (With voluntary enrollment, five- and 10-year savings would drop to $6.1 billion and $31.7 billion, respectively.) Commonwealth also estimates that enrolling 75% of Medicaid recipients in medical homes would save $16.8 billion in five years.
Demonstration projects testing the model, including a long anticipated but much delayed Medicare 36 practice project, are scarce. At present, most PC-MH cheerleaders point to Community Care of North Carolina’s (CCNC’s) 15 networks, 3500 PCPs, and 1000 medical homes as a successful prototype. Since 1999, all of North Carolina’s 750,000 Medicaid beneficiaries have a medical home. The state pays PCPs 95% of Medicare reimbursement plus $3 per member per month (PMPM) for case management and $3 PMPM for care/disease management. For fiscal years 2005 and 2006, CCNC saved $231 million.
Nationally, the $6 PMPM seems too low; other states might add $12-$16 to traditional FFS. A hybrid system of FFS plus a bundled medical home payment based on a practice’s providing one of three levels of medical home services seems likely (see sidebar, PC-MH Practice Sophistication).
Overall, the medical home’s proponents are on a roll, but the concept could be derailed in several ways. Conspicuously absent is the AMA’s endorsement. In addition, PCPs are still retiring in droves with few newly minted generalists to take their place. Dr. Hessan emphasized the need for prompt action to retain them: Medical manpower in Maryland is critically short. Reimbursement is generally low for us, and worse for PCPs. These problems will only get worse over time if PCPs aren’t incentivized in the way that the medical home suggests.
Practice Readiness for the Medical Home
Here are the guidelines from the American Academy of Family Physicians (AAFP), the American Academy of Pediatrics (AAP), and the American College of Physicians (ACP) on practice readiness for implementing a Patient-Centered Medical Home:
Standard 1: Access and Communication
- Written standards for patient access/communication
- Uses data to meet standard
Standard 2: Patient Tracking Registry
- System for nonclinical patient information
- Has and uses clinical data system
- Paper or electronic charts to organize information
- Uses data for diagnosis and condition identification
- Generates patient lists and reminders
Standard 3: Care Management
- Uses evidence-based medicine for three conditions
- Uses reminders for physicians to do preventive care
- Uses nonclinical staff to manage patient care
- Care management follow-up
Standard 4: Patient Self-Management Support
- Deals with language barriers
- Enhances patient self-support
Standard 5: Electronic Prescribing
- Electronically write prescriptions
- Electronically check prescriptions
- Electronic cost control
Standard 6: Tests
- Tracks tests, gets abnormal results systematically
- Uses electronic system to order tests and detect duplicates
Standard 7: Referrals
- Tracks referrals with a paper or electronic system
Standard 8: Performance, QI
- Measures clinical metrics by physician or across the practice
- Surveys patients
- Has goals for QI
- Generates QI reports
- Transmits QI reports electronically to outside agencies
Standard 9: Advanced Electronic Communication
- Interactive Web site
- Electronic patient identification
- Electronic care management supports
Source: NCQA PPC-PCMH Content and Scoring, 2007
PC-MH Practice Sophistication
The PC-MH model would reimburse practices based on their implementing medical home elements. Payers would reimburse a medical home at one of three levels, with Level 3 receiving the highest reimbursement. Each element would be graded on a pass/fail basis, with points allocated as follows:
- Access & Communication (9)
- Patient Tracking & Registry Functions (21)
- Care Management (20)
- Patient Self-Management Support (6)
- Electronic prescribing (8)
- Test Tracking (13)
- Referral Tracking (4)
- Performance Reporting & Improvement (15)
- Advanced Electronic Communication (4)
Total Points: 100
Level 1 = 25-49 points
Level 2 = 50-74 points
Level 3 = 75+ points
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©2008 The Triological Society