Health Care Reform=The Patient Centered Medical Home
By Patty Blevins
May 25, 2022
What is the Patient-Centered Medical Home?
The United States healthcare system is in the midst of transformation due to a problematic past.
In a fragmented health care system, a 70-year-old patient admitted to the hospital due to a foot ulcer is at greater risk for poor outcomes. Who would assume the responsibility of overseeing his care for this chronic condition? Who would do the work of obtaining inpatient records, collecting consultation notes, and lab results and x-ray reports? How would primary care and specialists collaborate? How could the patient ask a question without feeling that he was a burden on office staff? How would this individual case contribute to population health?
This case has multiple points requiring coordination of care that weren’t present, resulting in an American healthcare system that was financially costly and of poor quality.
On the other hand, the patient-centered medical home (PCMH) is at the center of health care reform and has been one of its strongest drivers. (1) It is a giant leap toward health and wellness in the United States. It is a technology-enabled framework for primary care delivery; primary care has shown the greatest promise for improving health care outcomes. It’s been a buzzword in health care for years and gained momentum from the article “Crossing the Quality Chasm” (2001) by the Institute of Medicine (IOM) and most recently in the Affordable Care Act (2010). It originated in 1967 and was effective in treating children with multiple needs.
The PCMH is a restructuring of primary care delivery that positions the primary care physician or nurse practitioner as the leader and the patient in the center, surrounded by a team of professionals versed in healthcare equity and culturally sensitive.
There is urgency toward adopting the PCMH as the number of complex chronic diseases increases, baby boomers are aging, and the general population is living longer.
As momentum towards the PCMH continues, there are implications for different entities within the healthcare industry, such as consumers, primary care, payers, and information technology. In this blog, I’ll point out the implications of the adoption of the PCMH for these groups and show how it is accepted nationally as the gold standard for primary health care.
What are the implications for consumers, primary care providers, payers, and information technology?
At a PCMH, a patient (or consumer) can expect to assume more responsibility as they make decisions about the direction of their care. A long-term relationship with a team of providers supports health maintenance. Clinician lead teams coordinate care, especially for the prevention and treatment of chronic diseases. Clinicians will educate the patient on community resources. The patient will have better access through expanded hours and electronic communication. Treatment will involve behavioral health care. (2)
Primary care has the most significant potential for turning the tide toward quality healthcare. “In areas where primary care is strong, patients have better outcomes and are more satisfied, while health disparities and healthcare costs are lower.”(3) Physician satisfaction scores with the PCMH have increased. Providers would have access to “the most comprehensive clinical data available” through technology communication with health plans. (3)
When considering payers or health plans, the PCMH has decreased hospital and emergency room admissions. In reimbursing care at a PCMH, payers are assured of payment for quality. The PCMH creates competition between health plans as those plans that are willing to collaborate by sharing the extensive data of their members are preferred. (3)
Information technology concept. Coding programmer language script text on screen monitor display. Programmer occupation job. Selective focus.
Technology enables the PCMH. Technology fills the gaps of a fragmented system and allows for the high degree of information exchange required by a PCMH. Those vendors that succeed at interoperability and work with the federal government in standardizing information flows will do well. Technology allows for more efficient workflows and contributions of data to population health. It collects meaningful data to advise treatment direction and enable data exchange with health plans. It collects data so that a single episode of hospitalization or a new diagnosis contributes to population health. (3) It promotes safer care by making the best practice the easiest thing to do. It can make evidence-based practice and clinical guidelines easy to access. Technology allows for patient portals where patients can access their records and ask the provider a question.
The NCQA assesses quality.
The National Committee for Quality Assurance (NCQA) accredits the PCMH. The NCQA scores practices on six areas that define patient-centered homes: enhanced access, use of data for population management, care management to plan and manage care, self-care support and community resources, referral tracking and follow up and measure and improve performance. Scores result in a recognition level of 1,2, or 3, and states and other payers often tie payment to the level of PCMH recognition practices achieved. (2)
The PCMH plays well with other healthcare reform measures.
- The PCMH fulfills the Triple AIM goals designed to optimize health system performance. (Institute of Healthcare Improvement). PCMHs decrease cost, improve the quality of health care and patient satisfaction. (5)
- The Medicare Access and Chip Reauthorization Act (MACRA) rewards clinicians who earn NCQA PCMH recognition and patient-centered practices recognition. MACRA is a payment program from the Center for Medicare and Medicaid Services. (5)
- The PCMH is a strategy that organizations can use to deliver value-based care.
- The Center for Medicare and Medicaid Services (CMS) supports multi-payer initiatives to learn how to align local, regional, national, and provider interests to scale and spread best practices and optimize both payment and delivery reform. (5)
- The Patient Protection and Affordable Care Act of 2010 strongly encouraged the growth of PCMH. (6) “PCMHs are the fundamental building block for meeting NCQA’s rigorous standards for accrediting accountable care organizations (ACO)”. (5)
According to a recently published PCMH recognition Fact Sheet, more than 13,000 practices (with more than 67,000 clinicians) are recognized by the National Committee for Quality Assurance (NCQA).
Currently, there are nearly 500 public and private sector PCMH initiatives being tracked across the United States. (2)
Progress has been slow in adopting this transformative framework for healthcare delivery. One of the reasons is the cost to start up. PCMH transformation can take from $83,000- 346,000 per annum for a process that can take years to complete. (1). Other barriers are acquiring interoperability of the electronic health record and alignment across multiple payers. (3)
The adoption that has occurred shows evidence of its effectiveness. PCMH providers have been able to increase life expectancy, save millions through the better management of chronic diseases, decrease preventable readmissions by improving care coordination and ensure better compliance with primary care. Patients are more satisfied when treated at a PCMH. (1)
- Bresnick, Jennifer. Breaking Down the Basics of Patient-Centered Medical Home. Feb. 25, 2015. HealthITAnalytics. https://healthitanalytics.com/news/understanding-the-basics-of-the-patient-centered-medical-home
- Patient-Centered Medical Home NCQA fact Sheet.
https://www.ncqa.org/wp-content/uploads/2019/05/20190425_Employer_Engagement_PCMH.pdf
- Adamson M. (2011). The patient-centered medical home: an essential destination on the road to reform. American health & drug benefits, 4(2), 122–124.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4106584/
- Wooldridge, Scott. Primary care “medical home” catching on slowly. Benefits PRO. April 24, 2019.
- Patient-Centered Primary Care Collaborative. The Patient-Centered Medical Home FAQ sheet. https://www.pcpcc.org/sites/default/files/page-files/What-is-a-PCMH-FAQ_0.pdf
