Friday, October 9, 2009

Patient Centered Medical Home

The fundamental challenge for health reform is to expand access, while changing the delivery system to provide higher quality care at a lower cost. Current reform success will require a shift in emphasis from fragmentation to coordination and from highly specialized care to primary care and prevention. The Patient Centered Medical Home (PCMH) model is one method to move us in this direction. The PCMH model is founded on 4 cornerstones: primary care, patient centered care, new model practice, and payment reform. Patient centered care is designed to meet the needs and preferences of patients.

The term "medical home" was first used in a book published by the American Academy of Pediatrics (AAP) in 1967 Pediatric Records and a "Medical Home" In: Standards of Child Care. The initial premise was that children with special needs (defined as children with severe chronic illness, developmental disabilities and birth defects or others with high care needs) should have care coordinated by a practice that provided "accessible, coordinated, family centered, culturally effective care by a pediatrician who in addition provides primary care and manages and/or facilitates all aspects of the care for these children."

While the PCMH would encourage patients to identify a medical home, the physician practice would function to inform, coordinate and facilitate specialty care where that care is likely to be of benefit to the patient. The proposed hybrid model of reimbursement includes a per patient per month or year payment, and that payment would be based on the degree to which the practice was using the technology, systems and care coordination specified in the PMCH. While the pay for performance component of the reimbursement might in part be based on resource use/cost, it would not necessarily differ in degree or focus from the same elements applied to sub-specialty practice.

A PCMH demonstration was undertaken Group Health, with the goals of improving patient experience, lessening staff burnout, improving quality, and reducing downstream costs. Five design principles guided development of the PCMH changes to staffing, scheduling, point-of-care, outreach, and management. Group Health provides healthcare insurance and comprehensive care to approximately half a million residents in the northwestern United States. Twenty primary care clinics are located in western Washington State, where patients choose a primary care physician to guide and coordinate their care. These physicians (81.6% family physicians, 3.5% general internists, and 14.9% pediatricians) care for an average of 2300 patients and work in multidisciplinary teams

The PCMH model outlines a payment structure that combines fee-for-service, pay-for-performance, and a separate payment for care coordination and integration. The payment structure is explicitly intended to provide compensation for care coordination, care management, and medical consultation outside the traditional face-to-face visit. The model also calls for financial recognition of case-mix differences, the adoption and use of clinical information technology for quality improvement, savings from reduced hospitalizations, and the achievement of quality targets.

Each of the 4 cornerstones of the PCMH model has its unique strengths and vulnerabilities. Another challenge to the success of the PCMH model is public perception. For some, "medical home" sounds a lot like a nursing home and initial resistance could be difficult to overcome. Also the expectation of short-term cost savings may be unrealistic in many areas. Implementation of the PCMH model will require infrastructure investment and retooling in the primary care practice.

Built on the four cornerstones of primary care, patient centered care, new model practice, and payment reform, the widely endorsed PCMH model has the potential to increase access and quality and to decrease the rate of growth in costs over time. As health reform gains momentum, the PCMH model will become increasingly important.