The patient-centered medical home: Understand why and how it’s changing primary care

The second in an ISMA Reports series*

e-Reports, December 3, 2012

This part of the series on the patient-centered medical home (PCMH) looks at why the model is advancing after decades of stagnation. (See Part I in the Nov. 19 issue.)  What is it about the current health care delivery environment that has given energy to this idea and how ill it impact even specialty physicians?

An environment ripe for change

Few would disagree that health care delivery in the U.S. needs to change. Most estimates show medical care is nearing 20 percent of GDP. More importantly, it’s already more expensive than average Americans can afford.
But doctors aren’t happy either. Check results of The Physicians Foundation survey in our Nov. 5 issue that revealed 68 percent of physicians nationally felt very or somewhat negative about the current state of the medical profession.

Doctors are increasingly looking for different ways to care for patients and many are integrating with hospital systems.  Accenture Physician Alignment Research estimates that by the end of 2013, only 36 percent of physicians will practice independently. Those remaining will work under different payment models, moving away from fee-for-service volume.

At the same time, physicians want fewer administrative hassles, reduced patient loads and help with the business side of medicine.  Patients are demanding increased access to care – meaning evening and weekend visits – and more value for their health care dollar. The Affordable Care Act gave momentum to PCMH as a way to better coordinate care, and the 2013 physician fee schedule does offer increased pay for that care coordination.

A medical neighborhood

“Specialists are an important part of the medical neighborhood,” said Community Health Network’s Kathy Staples, M.B.A., B.S.N., PCMH operations manager. Staples has worked with the first two of Community’s physician practices that are moving toward PCMH recognition by National Committee for Quality Assurance (NCQA) early next year; others will follow.
“The EHR was a huge step,” said Staples. “The EHR certainly provides greater communication within the practice and across the network – available now to specialists and others who can provide better care with health records at their fingertips.”

Staples looks forward to improved internal processes – encouraging openness and cooperation between primary care and specialty practices. The idea is to decrease the costs of testing, explained Staples. More importantly, she said, “PCMH pulls specialists into the health care team and strengthens partnerships.”

While PCMH is a model for primary care, some specialty practices can serve as medical homes for patients with chronic, complex diseases. For example, a cardiologist may be a medical home for a patient with a complicated cardiac disease.

A better life for physicians

Eric Wright, Ph.D., director of the Center for Health Policy at IUPUI, sees PCMH as having the potential to improve the quality of life for physicians because of its team approach.
“Now when physicians work with challenging patients, they are working alone and can sometimes reach a wall with those patients,” he said. “Having another person from the team to step in may be more effective than a single interaction.”

Dr. Wright sees some stress relief from PCMH physicians who may benefit from having multiple physicians to help provide more reasonable coverage.  And while he understands the skepticism of some, he advises physicians to pay attention because this time – for the first time in the U.S. – the whole health care package is transforming.

The team-based approach of PCMH moves past the gatekeeper idea from past days of managed care. “In traditional managed care, incentives were for decreasing care, whereas with PCMH the reward will be for encouraging more effective care – pay for quality and not a focus on decreasing quantity of services as it was under managed care.”

In the past, changes were made incrementally; it was managed care in isolation, he said. “PCMH is now the clinical lynchpin of major reform efforts, so it’s not a fad.”

Graph Source: The Hidden Epidemic: Finding a Cure for Unfilled Prescriptions and Missed Doses. December, 2003. The Boston Consulting Group and Harris Interactive. Available here.

*Part III of the series in the next ISMA Reports will discuss lessons learned and early results.