Recently, I attended the Institute of Health Care
Improvement conference in Washington, DC.
One thing was clear, the concept of patient centeredness is currently at
the forefront of primary care, and regardless of the Affordable Care Act’s
political fate, the Patient Centered Medical Home (PCMH) is coming into
prominence. However the definition of
the PCMH is fluid – over 40 definitions pop up if searched on Google. This post will hopefully allow you to answer
the question “What is a PCMH?” and thus gain social prestige and recognition
among your peers.
It could be said that many parts of our current health care
system are physician-centered. Access to
the a physician is limited, requiring scheduling significantly ahead of time or
long waits for a same day visit.
Additionally, communication amongst physicians is minimal, patients
often shuttling documents back and forth between providers. Finally, care can often be reactive rather
than proactive, the system only cares for someone once they present with an
acute issue, rather than working actively to keep the person healthy in the
first place. (Iglehart
2008)
To be fair, the described scenario is “primary care gone
wrong”, many physicians do make a tremendous effort to practice in alignment
with the 4 “pillars” of primary care: comprehensiveness, coordination,
continuity, and contact. (Harper
and Balara ) These values as well as others are incorporated
into the definition of the PCMH. For
some, the PCMH is a transformative model of care to others it is merely a label
to what is already happening in many clinics; the utility of the term is it
brings the existing values of primary care into the folds of a productive
political dialogue.
Patient centered care is an umbrella term for a style of
care that adheres to specific core values.
PCMH is the name for a provider, usually a primary care physician (PCP),
currently practicing patient centered care.
Many primary care physicians are in the process of certifying their
outpatient services as a PCMH. The
building is the same and the doctors are the same, but the care process is
modified. Many may mistakenly think that
a PCMH is a type of building or a specific arrangement of providers, this is
not the case.
The term Patient Centered Medical Home was first coined by
the American Association of Pediatrics in the 1960’s who noticed that children
with complex illnesses needed a different approach to care - coordinating the
many physicians and social services associated with the management of a
disease. Currently PCMH is a term used
by the National Committee for Quality Assurance (NCQA) – a not-for-profit
company that provides the PCMH certification.
This brings us to the first point; PCMH certification is a
business. There are currently 4
organizations that provide patient centered care certification. Each organization charges a practice to
become certified and each uses its own, slightly different, language to talk
about patient centered care. The NCQA
has been certifying practices the longest – 3 years – and uses the terms
“certification” and “Patient Centered Medical Home.” The Utilization Review Accreditation Counsel (URAC),
by contrast, has only been “accrediting” practices for the past year and uses
the term “Patient Centered Health Care Home” (PCHCH).
Don’t let the language confuse you, all of the
certifications fall under the umbrella term of “patient centered care” and the
concept of a “medical home.” Though the
details of each certification process vary, they all focus around key values
that are central to the medical home.
The NCQA requirements are the most commonly accepted and are presented
in several broad categories:
-better access
-coordination of care
-active management of care
-support for self-care
-performance improvement
-use of data systems
So what would a PCMH look like? Imagine a clinic that had same day
appointment slots for urgent visits or could schedule a normal visit within 3
days; the office offered weekend hours and after-work hours as well. Additionally you could email your physician
for easy requests like a refill for a longstanding prescription.
The care would be comprehensive, allowing a patient to have
most or all medical needs addressed in one location – including the management
of some complex cases usually in need of a specialist. In the event a patient must see an outside physician,
the PCMH also exchanges information with surrounding providers allowing your
primary care physician (PCP) to access clinic notes and tests from other doctors
instantaneously.
Electronic medical records would track preventive care
measures and actively contact and flag patients for screening or
education. The office would provide an
array of materials for patients to manage their own health care which could be
accessed online, patients can also view lab results and their medical records
online through the clinic’s website.
Finally, clinics would track the health of their patient population,
report the results publically, and use the information to improve their care
processes.
Clinics are pushing for the PCMH certification because many
insurers are starting to reimburse PCMHs better or pay a per-member-per-month
flat rate to PCMH certified clinics. The
financial rationale is that PCMHs provide a type of care that reduces emergency
room visits and hospitalizations from acute complications of chronic diseases –
both extremely expensive types of care.
What stands in the way of us and this utopic vision of the
primary care? One issue is that care
often involves many providers; as comprehensive as care may be in the medical
home, there will be patients that seek care from other providers – either by
need or preference. Doctors not associated
with the PCMH – and not receiving the financial benefits from payers – have no
reason to coordinate with the PCHM.
Care coordination is expensive and it would be a poor choice to invest
in the infrastructure needed unless there was a financial benefit to offset the
cost(Fisher
2008).
Additionally, fee-for-service makes new models of care
challenging. For example, physicians
have no way of coding an e-mail contact for reimbursement. For this reason, some doctors refuse to do email,
claiming that it is an uncompensated increase in their workload. Fee-for-service also doesn’t pay for the
additional administrative costs of tracking and coordinating care across
providers(Fisher
2008).
There are answers out there, but nothing is certain. Increased payment for PCMHs in a
fee-for-service structure may give the financial buffer for doctors to engage
in uncompensated care processes such as coordination and electronic
access. Similarly, a
per-member-per-month flat rate can be used to cover the same processes.
PCPs are also experimenting with additional ways of
consulting specialists – such as a tele-consult. This would allow a PCP to benefit from the
expertise of the specialist and the patient can still receive all of her care
at the PCMH. The PCP pays the
specialist a per-episode fee in exchange for the consult so the specialist has
a financial interest in collaborating.
The arrangement allows a broader array of services to be provided from a
single office, far better for the patient in terms of convenience and
coordination.
Congratulations, you are one of the few that have survived, still conscious, another journey into the churning waters of healthcare reform. I bid you farewell and urge you to make an effort to socialize more with your peers rather than reading articles such as mine. Until next time...
References
Fisher ES. 2008. Building a medical
neighborhood for the medical home. N Engl J Med 359(12):1202-5.
Harper MA and Balara JAE. Patient
centered medical home. .
Iglehart JK. 2008. No place like
home—testing a new model of care delivery. N Engl J Med 359(12):1200-2.
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