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The Patient-Centered Medical Home

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1 The Patient-Centered Medical Home
Prepared by: Kelly Doran, MD NYU/Bellevue Emergency Medicine

2 Introduction What is a patient-centered medical home? What does it mean for emergency medicine? Will the PCMH model improve health care?

3 Objectives Discuss the development and key features of the PCMH model Understand implications of the PCMH model for emergency medicine Delineate ACEP’s position on the PCMH Explore current implementation of the PCMH

4 What is a Patient-Centered Medical Home?
“An enhanced model of primary care in which care teams attend to the multi-faceted needs of patients and provide whole person comprehensive and coordinated patient-centered care.” “A model of care where each patient has an ongoing relationship with a personal physician who leads a team that takes collective responsibility for patient care.” Many different descriptions…First from Building Medical Homes article from Commonwealth Fund (Kaye), second from NCQA news release Others from Commonwealth Fund President’s message: “An approach to primary care organized around the relationship between the patient and the personal clinician” and primary care that is “accessible, continuous, comprehensive, family-centered, coordinated, compassionate, and culturally effective.”

5 History of the PCMH 1967: Concept first introduced by the American Academy of Pediatrics (AAP) 2001: The IOM’s Crossing the Quality Chasm: A New Health System for the 21st Century states that “the system of care should revolve around the patient.” 2004 & 2006: The American Academy of Family Physicians (AAFP) and American College of Physicians (ACP) put forth their own statements regarding medical homes 1967 – when AAP introduced the concept it was as a place to archive a child’s medical records, so somewhat different from today’s definition

6 History of the PCMH 2006: Fewer medical students entering primary care
2006: The Patient Centered Primary Care Collaborative (PCPCC) was formed, representing employers, medical specialty societies, health insurance plans, and other stakeholders 2007: Joint Principles of the Patient-Centered Medical Home is put forth by the AAP, AAFP, ACP, and AOA (American Osteopathic Association) 2006: Noted that far fewer medical students entering primary care, which intensified the “crisis of primary care discussion” PCPCC initiated from the industry side/business, particularly with leadership from IBM – large national employers who were interested in improving health outcomes and undoubtedly decreasing costs. Currently the PCMH model has been endorsed by nearly all the major national health plans, most of the Fortune 500 companies, consumer organizations and labor unions, the AMA, and 18 specialty societies.

7 Joint Principles of the PCMH
Personal physician Physician directed medical practice Whole person orientation Care is coordinated and/or integrated Quality and safety Enhanced access to care Payment reform 1. Personal physician - Each patient has an ongoing relationship with a personal physician. 2. Physician directed medical practice - Personal physician leads a team of people who collectively take responsibility for the care of patients. 3. Whole person orientation – Personal physician is responsible for providing for all of the patient’s health care needs or taking responsibility for appropriately arranging care with other professionals (includes care for all stages of life, preventive services, and chronic care) 4. Care is coordinated and/or integrated – across all elements of the healthcare system (subspecialty care, home health care, nursing homes, hospitals) and patient’s community (family, public and private community-based services), facilitated by information technology, to assure patients get indicated care when and where they need and want it in a culturally and linguistically appropriate manner. 5. Quality and safety are hallmarks of the medical home – patients actively participate in their care, IT is used appropriately, voluntary physician engagement in performance measurement and improvement, evidence-based medicine and clinical decision-support tools guide decision making, practices go through a voluntary recognition process by an appropriate non-governmental entity to demonstrate that they have the capabilities to provide patient centered services consistent with the medical home model. 6. Enhanced access to care through systems such as open scheduling, expanded hours, and new options for communication between patients and their personal physician or other practice staff. 7. Payment appropriately recognizes the added value provided to patients who have a PCMH/Payment Reform. The payment structure should reflect the value of patient-centered management work that falls outside of the face-to-face visit, it should allow for separate fee-for-service payments for face-to-face visits, it should pay for services associated with coordination of care, it should allow physicians to share in the savings from reduced hospitalizations (and much more re: payment – 9 separate points on payment). It would include fee-for-service, pay-for-performance, and a separate payment for care coordination , case management, and medical consultation outside the traditional face-to-face visit

8 The PCMH and Emergency Medicine
The PCMH model is hoped to: Decrease “non-urgent” emergency department use Help patients control their chronic illnesses to avoid needing emergency care Reduce hospital admissions Improve patient care overall

9 ACEP’s Response “The realities of our current dysfunctional healthcare system stand in stark contrast to the laudable goals of the PCMH.” - ACEP Policy Statement

10 ACEP Policy Statement “Important specifics must be addressed before moving forward with widespread adoption of the PCMH model. Nowhere is caution more important than in the way implementation of the PCMH model might negatively impact the emergency department.” - ACEP Policy Statement Will move on to talk about what those specifics are and how the PCMH might negatively impact the ED. Will do the latter one first.

11 The PCMH and Emergency Medicine: The Concerns
Resources used to develop the PCMH model might reduce support available for emergency medicine The PCMH model might draw attention away from an emergency system that is the “ultimate safety net” for patients Concern that money might be taken from the emergency system that is already “at the breaking point.” This assumes though that it is a “zero sum game.” There is no indication so far that money has been directed from emergency to PCMH. Though emergency rooms are crucial in serving those with life-threatening illness, they do also serve a role as a safety net for people who otherwise fall through the cracks

12 ACEP agrees with the basic principles of the PCMH…
ACEP Policy Statement ACEP agrees with the basic principles of the PCMH… With the caveat that eight critical issues should be addressed ACEP recognizes that health care would improve with increased access to personal physicians

13 ACEP Critical Issues “ACEP supports high quality, safe, and efficient medical care” “ACEP supports health care payment reforms that ensure all medical providers are fairly compensated for the care they provide to patients” Must compensate physicians for EMTALA-mandated services If they’re going to get some, we should get some too (re: reimbursement).

14 ACEP Critical Issues “Enhanced access must be demonstrated”
“Once established, the medical home should continue regardless of insurance status or ability to pay.” Currently, most primary care practices are small, not open nights or weekends, and patients have trouble getting appointments even during regular hours. 1/3 of primary care practices are 1 or 2 physicians (Rittenhouse). So PCMH’s must demonstrate that they can provide the continuing access to a personal provider that is key to the model Patients must be able to maintain their personal physicians even if their insurance changes or they become uninsured If these things aren’t fulfilled there is really no point to the PCMH model – it wouldn’t be much different from what we have now

15 “The medical home must include the safety net of emergency care.”
ACEP Critical Issues “Universal health insurance coverage is necessary for the PCMH model to be most effective.” “The medical home must include the safety net of emergency care.” Currently the uninsured are left “homeless” by the PCMH model. Research has shown that insured children are more likely to be a part of a medical home than uninsured children (Starfield and Shi, 2004) Emergency medicine is going to remain valuable no matter what and we must safeguard it, especially as it is already stretched to the limit. Resources dedicated to the PCMH must not be taken from those needed by emergency medicine

16 ACEP Critical Issues “Patients must have freedom to switch medical homes, select specialists of their choosing, and access emergency medical care when they feel they need it.” Patients, not gatekeepers, should decide what is an emergency by “prudent layperson” standards “Research must prove the value of the medical home before it is widely adopted.” And they should not be denied coverage for the ER visit if in retrospect their diagnosis was not an emergency

17 Current Implementation
Medical home initiatives exist in all states Both publically and privately funded CMS to start a 2010 demonstration project in 400 practices in 8 regional sites Bills promoting the PCMH model have been introduced in at least 16 states Medical home initiatives in all states (Homer, et al. 2009) Medicaid and SCHIP running medical home projects in several states, others run by health plans or are multi-stakeholder (coordinated across a number of health plans help spread the impact on participating primary care practices.) CMS = Centers for Medicare and Medicaid Services See CQ State Track for legislation info, PCPCC demo book for current demo projects, Rittenhouse and CMS website for CMS info

18 How to Evaluate the PCMH?
National Committee for Quality Assurance Set nine standards that practices must sufficiently meet to attain recognition as a PCMH Voluntary Criticisms of NCQA Standards Too much emphasis on information technology and not enough on patient-centeredness NCQA program called Physician Practice Connections – Patient-Centered Medical Home (PPC – PCMH). Also, practices must meet at least 5 of 10 critical elements.

19 Results of Initial Research: The Good
Geisinger Health System in Pennsylvania  20% reduction in hospital admissions and 7% savings in overall medical costs (Paulus 2008) Study of asthmatic children on Medicaid in North Carolina (Domino, et al. 2009)  Fewer ED visits and hospitalizations but higher costs One PCMH in Seattle (Reid 2009)  Increase in patient-level markers, no change in costs One important note is that one often sees proponents of PCMH citing a cost savings of $ million dollars in a North Carolina program “Community Care of North Carolina,” but this program included only certain elements of the PCMH as it is currently defined (Steiner NC article) Geisinger info from Paulus article. Geisinger has 2.5 million patients (poorer, older, sicker than average), 700 physicians, 55 practice sites, three hospitals It is important not to confuse benefits of primary care with benefits specific to the patient-centered medical home model Domino study—> Decreased hospitalizations and ED use in MH vs. fee-for-service plans (smaller difference when compared to managed care plan). Increased Medicaid costs for both MH and managed care plans vs. FFS Reid study  patients in PCMH had more contact; small but significant improved opinions on quality of doctor-patient interactions, shared decision making, coordination of care, and access; no change in costs

20 Results of Initial Research: The Bad
“Initial lessons” from AAFP demonstration project of 36 family practices  “Our early analysis raises concerns that current demonstration designs seriously underestimate the magnitude and time frame for the required changes, overestimate the readiness and expectations of information technology, and are seriously undercapitalized.” (Nutting, et al.) Commonwealth Fund study of 35 practices  Higher IT costs for PCMH, otherwise no significant increase in costs for higher “medical homeness” Felt that implementing the PCMH requires “epic whole-practice reimagination and redesign” not just small incremental changes, requires mindset shift in physicians, will likely require more than three years for practice transformation in the NCQA process while at the same time being hopeful and saying that “the PCMH represents a pivotal turning point for the restoration of a healthy primary care foundation and better health for our nation.” Commonwealth fund study (Zuckerman et al. 2009)

21 Conclusions PCMH model is being implemented
Looked to as important part of health care reform PCMH has major issues not resolved “Society must get the home it is paying for” Need to address fundamental concerns Potential is there, but further data needed The concept sounds very good and has great potential, but it remains to be seen how successfully it can be implemented.

22 References Abrams MK, Davis K, Haran C. Can patient-centered medical homes transform health care delivery? Commonwealth Fund: From the President. 27 Mar 2009. American Academy of Family Physicians, American Academy of Pediatrics, American College of Physicians, American Osteopathic Association. Joint principles of he patient-centered medical home Berger E. Medical home: A solution to “hamster health care” or a drain on emergency care? Annals of Emergency Medicine ;52(6): CQ State Track Free Nationwide Bill Search. Available at Search conducted 26 Jul 2009. Domino ME, Humble C, Lawrence WW, Wegner S. Enhancing the medical homes model for children with asthma. Med Care. 2009;47: Homer CJ, Cooley WC, Strickland B. Medical home 2009: what it is, where we were, and where we are today. Ped Ann. 2009;38(9): Kaye N, Takach M. Building medical homes in state Medicaid and CHIP programs. National Academy for State Health Policy and The Commonwealth Fund. June Available at NCQA News Release. NCQA program to evaluate patient-centered medical homes. 8 Jan Available at Accessed 8 June 2009. Nutting PA, et al. Initial lessons from the first national demonstration project on practice transformation to a patient-centered medical home. Ann Fam Med. 2009;7(3): The Patient-Centered Medical Home. ACEP Policy Statement. Approved by the ACEP Board of Directors August Available at: Patient-centered medical home building evidence and momentum: a compilation of PCMH pilot and demonstration projects. Patient-Centered Primary Care Collaborative Available at: Patient-Centered Primary Care Collaborative web site. Paulus RA, Davis K, Steele GD. Continuous innovation in health care: implications of the Geisinger experience. Health Affairs. 2008;27(5): Reid RJ, et al. Patient-centered medical home demonstration: a prospective, quasi-experimental, before and after evaluation. Am J Managed Care. 2009;15(9):e71-e87. Rittenhouse DR, Shortell SM. The patient-centered medical home: will it stand the test of health reform? JAMA. 2009;301(19): Steiner BD, et al. Community Care of North Carolina: improving care through community health networks. Ann Fam Med. 2008;6(4):361-7. Starfield B, Shi L. The medical home, access to care, and insurance: a review of the evidence. Pediatrics. 2004;113(5 Suppl): Zuckerman S, et al. Incremental cost estimates for the patient-centered medical home. Commonwealth Fund Report. Oct Available at

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