January 4, 2010
Dear Partners,
As you may remember, we have been trying to take a step back from the past-paced activities surrounding federal and state legislation in order to provide you with more in-depth information about a variety of pediatric health care issues that are relevant to each of the six New England states. With help from our partners at the National Initiative for Children's Healthcare Quality (NICHQ), Children's Hospital Boston, and the Catalyst Center at Boston University School of Public Health, we are summarizing in this alert a noteworthy health care delivery model called the patient-centered medical home.
The patient- and family-centered medical home (PCMH) model is considered a core element of a transformed health care system, both at the state and national level. This model could significantly influence children's health by improving care coordination, access and quality of care. Along with improving health care delivery, this model has led to a reduction in unnecessary costs that are contributing to the high cost of our health care system.
Why the Need for Medical Homes?
The current U.S. health care system is fragmented and disorganized, too frequently leading to frustrating and unsafe patient experiences, wasteful duplications, inefficiencies and low-quality care. One of our current system's main flaws is that it is not focused enough on primary and preventive care, but is instead set up to reward and promote high-cost, invasive medical procedures.
Investing in and emphasizing the importance of primary care will help create a more efficient, cost-effective and high quality health care system. However, the traditional system of primary care can be significantly improved upon. Traditional ways of practicing primary care often do not adequately address how to manage chronic conditions and do little to reward system-wide coordination, education, or communication. The patient-centered medical home model aims to rectify the shortcomings of traditional primary care by aligning the incentives of patients and doctors with a team-based, coordinated approach.
Overview of PCMH
A PCMH model is designed to improve patient care by assigning a primary care provider to coordinate a patient's health care services, including specialists, hospitals and post-acute care. The PCMH encourages physicians to focus on the continuum of care for their patients that will ultimately improve health outcomes. One main goal of this centralized model is to eliminate unnecessary/redundant tests and avoidable hospital visits. In general, reimbursement is focused on care coordination efforts, reaching quality benchmarks, and implementing technology improvements. Many clinicians hope to adjust this payment system to better incentivize family engagement and long-term care coordination.
It is important to note that no two medical homes are exactly the same; physician organizations and payers are experimenting with different payment models and system structures to determine the most effective model. However, all provider practices that wish to be recognized as medical homes must first a meet set of standards developed by the National Committee for Quality Assurance (NCQA).
NEACH embraces the value of the PCMH as defined by the American Academy of Pediatrics[i] and the PCMH principles developed by the National Partnership for Women and Families[ii]. Other supporters of the PCMH model have joined together to form the Patient Centered Primary Care Collaborative (PCPCC), which represents employers, medical societies, health plans, consumer groups and other organizations.
We hope you find this information on the patient-center medical home to be helpful, and we encourage you to explore what PCMH efforts are taking place in your state.
As always, please feel free to contact me (617-275-2929, arosenthal@communitycatalyst.org) directly with questions.
Sincerely,
Amy Rosenthal
Project Director
How the PCMH Model Improves Children's Health
The term "medical home" goes back to 1967, when it was originally used to describe a centralized location for a child's medical records.[iii] It was thus created to address the needs of children, particularly those with special health care needs. Today, however, the term "medical home" is not exclusively linked to pediatric health care; many new medical home programs are aimed at meeting the needs of adults with disabilities or the elderly. In order to advance the medical home effort to improve children's health, it is important to keep in mind the unique developmental, psycho-social and physical needs of children.
The PCMH model revolves around the coordination and care efforts of the primary care team. There is evidence that high quality primary care improves outcomes for children and that communities with good primary care have better outcomes and lower costs.[iv] The four key components of the PCMH to promote and achieve better health care for children are: 1. coordination of care, 2. quality of care, 3. access to care, and 4. focus on preventative care. Below we offer a brief description of these four components.
1. Coordination of Care
The PCMH model significantly reduces the fragmentation of health services by assigning one physician to supervise all aspects of a patient's health care needs. Research has indicated that fragmented health care leads to worse health outcomes and increased costs to the health care system. Disjointed care is especially relevant to children who require frequent office visits and health status monitoring. Coordinating health services, on the other hand, has shown to reduce/shorten hospital stays, increase family involvement and decrease costs imposed on the health care system.[v] Therefore, it is imperative to promote the coordination and continuity of health services for the betterment of children's health. Coordination of care is achieved through:
- Adaptation of health information technology (HIT) which improves physician correspondence and patient tracking
- Reimbursement to the primary care physician for coordination efforts (not solely reimbursing physicians for in-office visits)
- Emphasizing patient and family involvement
- Employing and reimbursing a medical team based practice approach that utilizes supporting team members expertise in the treatment of patients
2. Quality of Care
The PCMH aims to improve and reward quality of care. This is done by:
- Designating the primary care provider as responsible for coordinating the patient's care (prevention, chronic and acute)
- Adoption of HIT which enables providers to better follow-up with their patients
- Adoption of electronic prescribing
- Ensuring timely appointments for the patient with the health care team
- Reimbursing providers for performance based on quality of care benchmarks and patient experience benchmarks
- Emphasizing the need for and development of national quality measures
3. Access to Care
Access to care is essential for children to be healthy. One requirement of the PCMH is that practices must provide extended office hours seven days a week or have other mechanisms in place to enhanced access. Longer hours allow for more patients to be seen in a timely manner. Another supporting factor for improving access is the office-based team approach, which allows for enhanced productivity of medical staff more efficient utilization of resources.
4. Prevention
The PCMH emphasizes prevention efforts and reimburses primary care physicians for providing preventive services, a practice that is currently rare in the conventional payment structure. The PCMH model is designed to reimburse physicians for meeting quality and cost saving benchmarks; this reinforces the necessity of preventative services which both improve quality of care and can save money down the road by preventing unnecessary and costly health problems. Focusing on prevention can significantly improve children's health now and promote healthy growth and development.
Existing PCMH Models
The PCMH is being piloted and tested across the country. Rhode Island has demonstration models in place, and Massachusetts has a goal to transform all primary care practices to Medical Homes by 2015.[vi] Two additional examples of PCMH pilot projects in New England can be found in New Hampshire and Vermont.
New Hampshire (see The Center for Medical Home Improvement for more information)
In 2007, New Hampshire began planning a medical home project for all children (including children with special health care needs). This project includes the development of a pediatric medical home network and registry. Another focus of this project is to create policy provisions regarding medical homes and provide technical assistance to practices designed as pediatric medical homes.
In a report in the Journal of Ambulatory Care Management, researchers found that the medical home model did improve children's health in New Hampshire; specifically, parents "reported fewer hospitalizations, fewer absent schools days, less worry about their child's health, and increased likelihood of having a written health care plan when their child's care was coordinated through a medical home."[vii]
Vermont (see Vermont Blueprint for Health for more information)
In 2008, three "Blueprint communities" were selected to pilot the PCMH model in Vermont. The key components to this pilot project are: "enhanced payment based on meeting nationally recognized quality standards, local multidisciplinary care support teams including prevention specialists, a web based clinical tracking system with eRx, and health information exchange."[viii] Evaluations are planned in order to determine the program's success, which will be based on clinical processes, patient health status, and quality of care. Based on a financial model, the Blueprint expects to save $100 million over expected normal growth by 2013.
Potential Implementation Issues and Challenges
Although the PCMH creates many incentives to improve patient care, there are some challenges that many practices face when transitioning into this model of care. First, the PCMH can involve significant implementation costs due to the reliance on HIT and the standard of longer office hours. Second, the lack of standardization around the payment structure may cause hesitancy among practices to make the changes needed to qualify as a PCMH. The final issue is that health care professionals not involved in the PCMH are not reimbursed for their coordination efforts, providing them little incentive to work collaboratively with providers in the PCMH settings. All of these issues, and a number of others, must be addressed in order to decrease the entry barriers for a practice to become a PCMH.
National Health Reform and the PCMH
There are many supporters of the PCMH who believe it can play a crucial role in national health care reform.
The Senate Leadership bill supports the development of training programs that focus on primary care models such as medical homes, appropriating funds for five years beginning in fiscal year 2010.
The House Leadership bill calls for Medicare and Medicaid pilot programs to test payment incentive models for accountable care organizations and to assess the feasibility of reimbursing qualified patient-centered medical homes. These models would then be adopted on a large scale if the pilot programs prove successful at reducing costs. Like the Senate bill, it also supports the development of interdisciplinary health training programs that focus on team-based models, including medical home models.
Key Message about PCMH
This model will not only improve the health of our children but it will also lead to cost-savings and efficiencies. This can only be accomplished if the PCMH is designed and implemented to include care coordination, access, quality incentives, focus on prevention efforts, cultural competence, the employment of a team based approach, and patient/family involvement.
[i] Medical Home Initiatives for Children with Special Needs Project Advisory Committee, American Academy of Pediatrics. Policy Statement: Organizational Principles to Guide and Define the Child Health Care System and/or Improve the Health of All Children. Pediatrics 110(1): 184-186 (July 2002). Reaffirmed Pediatrics 122(2):450. (August 2008).
[ii] Principles for Patient- and Family-Centered Care: The Medical Home from the Consumer Perspective. National Partnership for Women and Families. Retrieved on June 15, 2009 from http://www.nationalpartnership.org/site/DocServer/Advocate_Toolkit-Consumer_Principles_3-30-09.pdf?docID=4821
[iii] C. Sia, T. Tonniges, E. Osterhus & S. Taba. History of the Medical Home Concept. Pediatrics. Vol 113 No. 5 May 2004 pp. 1473-1478. Retrieved on June 23, 2009 from http://pediatrics.aappublications.org/cgi/reprint/113/5/S1/1473
[iv] Dartmouth Atlas of Health Care. Variation among states in the management of severe chronic illness, 2006.
[v] R. C. Antonelli, J. W. McAllister & J. Popp. Making Care Coordination a Critical Component of the Pediatric Health System: A Multidisciplinary Framework, The Commonwealth Fund. May 2009.
[vi] The Commonwealth Fund. Massachusetts: Connecting Health Coverage to Public Health. States in Action - June/July 2009. Retrieved on September 23, 2009.
[vii] http://www.prweb.com/releases/2009/07/prweb2653334.htm. Retrieved on July 20, 2009
[viii] Vermont Department of Health. (2009, January). Vermont Blueprint for Health: 2008 Annual Report. Retrieved on June 15, 2009 from http://healthvermont.gov/admin/legislature/documents/BlueprintAnnualReport0109.pdf
