What is a Patient Centered Medical Home, anyway?

Posted on June 12, 2012 by Robert Rowley

The Patient Centered Medical Home (PCMH) is a team-based health care delivery model focused on comprehensive and continuous care, sort of a coordinated one-stop-shopping approach to health care. It has been supported as a policy goal over the past several years, and is often mentioned along with Accountable Care Organizations (ACOs) as a way of maximizing healthcare delivery quality while saving on runaway healthcare costs that result from uncoordinated care.

Given that the PCMH model is not (yet) widely known by the general public, it may seem like something inconsistent with the traditional fee-for-service cottage industry that characterizes much of medicine in the U.S. Is this a new idea, merely theoretical, or is there emerging experience from which to measure whether there actually is the improved outcome that is touted? Let’s look a little deeper into these questions, and then (as is my leaning) see what kinds of health technology tools might need to be created to facilitate these changes in how health care is organized.

Emergence of the PCMH
The concept of a “medical home” was introduced as early as the mid-1960s by the American Academy of Pediatrics (AAP), envisioning a central source for medical information about a child. By the mid 2000s, other specialty boards, representing the bulk of primary care doctors in the U.S. – the American Academy of Family Practice (AAFP), the American College of Physicians (ACP), and the American Osteopathic Association (AOA), in addition to the AAP – came together to endorse a Joint Principles of the Patient-Centered Medical Home.

Given that a PCMH has certain elements that define it, several accrediting bodies have sought to “officially” designate Medical Homes. The most common has been NCQA Recognition; though URAC has a designation program, the Joint Commission has  PCMH Option for its Ambulatory Care customers, and the AAAHC has an accreditation program as well. Comparisons of the various accreditation programs has been published by the Urban Institute, and also by the MGMA.

There are several key features that a practice must demonstrate in order to be designated as a PCMH. They fall into 6 categories: (1) enhance access and continuity, (2) identify and manage populations, (3) plan and manage care, (4) provide self-care and community support, (5) track and coordinate care, and (6) measure and improve performance. Each of these categories has several specific elements that must be demonstrated, and each one has a “must pass” element which must be shown (at a 50% level or more): (1) access during office hours, (2) use data for population management, (3) care management, (4) support self-care process, (5) track referrals and follow-up, (6) implement continuous quality improvement.

Medical Home official Recognition has increased significantly over the past several years. According to a report by the NCQA in 2011, over 1,500 sites are NCQA Recognized, covering 7,600 clinicians (which means that an average PCMH site has about 5 clinicians in it):

Of interest, in the same document, one can see the geographic distribution of these sites. It is quite variable, and has a high concentration in the Northeast, particularly New York state:

Payment models
The PCMH model is founded on a primary care base, and as such needs to be able to support primary care. In a fee-for-service environment, primary care is compensated marginally, resulting in workforce attrition and scarcity. The various payment approaches used by PCMHs has been reviewed in the literature, and seem to fall into a 3-tier approach: (1) a fee-for-service base, encouraging “more pay for more work”, (2) a supplementary fixed management fee (a PCMH, after all, has much more active outreach and data-use than a traditional medical practice, thus needs more staff to do that), and (3) a performance-based bonus to reward achievement of measurable success.

Clearly, such a change in payment methods must get the support of payers (insurance plans), employers (those who pay the premiums for private insurance plans), and CMS (who pays for Medicare and Medicaid services). Convincing such payers that it is in their interest to change how they pay for health care, seemingly layering additional fees on top of what they are used to (fee-for-service), can take some doing – they must be shown how subsidizing a coordinated approach to health care not only improves quality, but also lowers cost. Is there evidence to show this?

Outcome data
To date, PCMHs are not mainstream, and their implementation has mostly been at the “demonstration project” level. These demonstration projects have been surveyed nationally, with the take-home lesson being that “payment reform is a cornerstone principle of the patient-centered medical home.”

A sentinel report in 2010 reviewed the experience of Medical Homes nationally, and categorized them into groups: (1) integrated delivery system models, (2) private payer sponsored initiatives, (3) Medicaid sponsored initiatives, and (4) other PCMH programs. Consistently, implementation of PCMH not only improved achievement of quality targets (like percentage of diabetic patients at target control), but also showed modest reduction in overall cost-of-care (to about 90% of “standard” cost for the population). One example in the report – the experience of HealthPartners Clinics, an integrated delivery system – was compellingly graphically shown:

Health IT requirements
Given all of this, it seems clear that we are at the beginning of dramatic changes in the landscape of health care delivery. The cottage industry of small 1-3 physician practices is fading, and PCMHs are increasing in their numbers, moving beyond the “demonstration project” phase and into the mainstream. The key to the success of this is the willingness of payers (public and private) to support a system different than traditional fee-for-service.

A PCMH needs structural changes (practice organization, patient access and experience) as well as robust use of technology. These are summarized nicely in an AAFP checklist.

What does it means for those who build the technology tools needed by health care? Ideally, a PCMH would need one comprehensive health IT tool that would address all its needs, rather than expecting a PCMH to have a collection of tools which somehow need to be linked together.

Health IT for PCMHs needs (at the very least) the following features:

1. A full EHR for chart note capture
2. Electronic prescribing, including medication interaction checking, allergy checking, formulary information and dosing alerts
3. The ability to create registry reports, and other robust reporting at-will for specific quality management programs that a PCMH may choose to focus on
4. A robust patient portal, including health education and self-help resources, as well as two-way communication with the clinic
5. The ability to track and monitor coordination of care, such as follow up of all referrals, labs and imaging that was ordered, as well as communication with home care and other community resources.
6. Clinical decision support resources delivered at the point of care, within the clinical workflow. This can be either Quality Measure compliance (“this patient is a diabetic and is due for a glycohemoglobin test”), or more complex library-style decision support (“what is the best way to address this set of symptoms and lab findings?”)
7. Clinical quality measures for the clinic – reports such as percentage of diabetics who have HbA1c less than 7 or over 9, etc. – which can be reviewed periodically and used for patient outreach or program development.

Health care is changing, and the landscape will look quite different over the next several years. Groups of physicians working in coordinated settings, like PCMHs, will become more commonplace, driven largely by the willingness of payers to support such change. The kinds of technology needed by this changing landscape can already be seen, though the specifics will likely emerge in surprising ways as PCMHs become mainstream. These are exciting times in health care and in health IT – the role of innovation has never been more important.

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