Patient-Centered Medical Home: The Future of Health-Care Delivery?
John I. Allen, MD, MBA, AGAF
Medical Director, Minnesota Gastroenterology
Chair, AGA Institute Clinical Practice & Quality Management Committee
Joel V. Brill, MD, AGAF
Chief Medical Officer, Predictive Health, LLC, Phoenix, Arizona
Chair, AGA Institute Practice Management & Economics Committee
Ronald Fogel, MD, AGAF
Digestive Health Center of Michigan, Detroit
Chair, AGA Public Affairs & Advocacy Committee
The federal government is notorious for reacting to, rather than anticipating, major trends in health care. We are too familiar with ongoing government efforts to reduce reimbursements for specific services and shifting dollars around the various pieces of a fixed financial pie; to call this "health policy"does not do the term justice. However, when reimbursement levels are adjusted in an attempt to construct new health-care policy, it will inevitably catch the attention of health-care constituencies.
The Patient-Centered Medical Home (PCMH) is a concept that has caught the attention of policymakers, corporations, insurers, state governments and specialty societies such as the AGA. In an era in which "higher quality at lower cost"has become the mantra, there was an appeal to the PCMH concept, leading us to convene, deliberate and make recommendations on the appropriate role of gastroenterology under such a health-care delivery system.
According to the American College of Physicians (ACP), a PCMH is a practice model in which a team of health professionals, coordinated by a personal physician, works collaboratively to provide high levels of care, access and communication, care coordination and integration, and care quality and safety throughout a patient’s lifetime. Specific charges of the PCMH range from coordination of information (at the simplest level) to assuming responsibility for total cost and quality of care. The PCMH practice is responsible for providing all of a patient’s health-care needs or appropriately arranging care with other qualified professionals. This includes provision of preventive services, treatment of acute and chronic illness, and assistance with end-of-life issues.
Some of the key drivers of the PCMH concept are workforce trends showing a marked decline in physicians choosing careers in internal medicine and primary care and inadequate reimbursements for primary care management. Within the concept of PCMH comes added reimbursement through a hybrid payment structure that includes a bundled, severity-adjusted, prospective care coordination fee; a per-visit fee-for-service payment; and performance-based bonuses. One unique aspect of the payment structure is that it includes reimbursement for coordination of care that is not a face-to-face activity. PCMH theoretically saves money by lowering resource inputs and decreasing utilization rates, avoiding emergency after-hour care, and improving quality while reducing Medicare spending — none of these have yet been proven to reduce costs.
While the PCMH model appeared intriguing, each of us had a number of questions. A fundamental question we identified was whether the PCMH would restrict patient choice. ACP indicates that the PCMH is not defined by specialty — any physician who has the training and experience to provide first contact, continuous and comprehensive care could be a patient’s "personal physician"in a PCMH. It is important to note, however, that gastrointestinal illness is not a focus of the PCMH. At present, the diseases of interest are cardiac/pulmonary and diabetes.
A key discussion point was the potential for shifting money away from procedural-based specialties. In a budget-neutral-payment world, how would the enhanced PCMH reimbursement be financed? Our concern was that CMS could value these services by decreasing funding for other Medicare services. Endoscopy fees could certainly be a target to help finance PCMH.
With regards to patient choice, the PCMH does not define the point of handoff of the patient to the specialist. The concept does not address the issue of exclusive contracts, potentially exposing the patient to a "gatekeeper"scenario.
How is the PCMH supposed to improve quality of care? A review of recent studies on chronic disease management did not show significant cost savings compared to usual care. It is unclear how patients with chronic diseases that are best managed by a specialist would benefit under the PCMH model. It appears that the PCMH is suited to patients with multiple chronic conditions that are usually managed by primary care physicians already. Underinsured patients would benefit only if they were actively recruited into a PCMH and could avoid using emergency room visits for basic health-care needs.
Our deliberations produced an 11-point set of principles to guide the AGA‚s efforts vis-à-vis PCMH (see below). Most importantly, PCMH must be voluntary. Specialists should be eligible to become a PCMH if they choose, but specialist reimbursement should not be decreased to pay for PCMH initiatives. And, "transition of care" and appropriate referral guidelines to specialists must be in place.
At present, commercial insurers and state and federal governments are developing demonstration projects to determine if the PCMH concept delivers what is promised. While improving care is laudable, our fear is that insurers and corporations will be watching only one aspect: Does PCMH save money? That issue alone could determine the future of PCMH. AGA will be actively involved, for we must ensure that patients have access to the best quality care for their digestive disorders.
Position Statement: Patient-Centered Medical Home Is an Appropriate Model for Treating Patients with Multiple Chronic Conditions
In order for the PCMH model to work best for gastroenterologists and their patients, the AGA recommends that the following principles be integral to PCMH to ensure accountability.
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PCMH must be voluntary. Patients should continue to have direct access to specialty care. Eliminating barriers to care and ensuring patient choice is essential to strengthening the doctor-patient relationship and ensuring that patients have access to the right care, at the right time, by the right provider in the right setting.
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PCMH should be bound to best patient value (in recognition that the best care must be coupled with efficient resource utilization). Physicians and patients must not be bound solely by exclusive PCMH contracts.
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Specialists should be eligible to become a PCMH, if they so choose. A specialist’s desire to provide women’s health care in conjunction with a gynecologist should not pose a barrier to becoming a PCMH, if the specialist can otherwise provide the range of clinical services required by the PCMH. For example, a gastro-enterologist could be deemed the PCMH for a patient with Crohn’s disease or hepatitis C.
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Accountability must be built into the PCMH model. Physicians must be accountable for the care that they provide their patients. Structural and quality measures should be an integral part in measuring responsible care. Accountability should also be measured by cost-effective care and outcomes, when appropriate.
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Guidelines appropriate to the specialty should be developed for appropriate patient care and used by the PCMH. Guidelines should include the development of algorithms to assist primary care and other PCMH physicians in the management of clinical conditions. Guidelines should be evidence based and developed jointly by primary care and specialty physicians.
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Clearly defined “transition of care” and appropriate referral guidelines to specialists must be in place for the primary care physician to use to further enhance quality, appropriateness and accountability of care. Measures should also include parameters for specialist episodes of care to ensure quality and success of care.
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Patient education is a key component to PCMH and quality patient care. Patients must be informed and provided information about health conditions and appropriate treatment guidelines to help them make their care decisions.
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Quality and price transparency should be accessible to patients to assist them in making informed health-care decisions.
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Health information technology (HIT) is a key component to the PCMH. While true interoperability must be in place, physicians should not be bound to the same electronic health systems. HIT features such as electronic medical records, e-prescribing and enhanced electronic communications among physicians and patients will improve coordination, quality and cost of care. It is recommended specifically that provider organizations and primary care groups work with specialists to facilitate HIT interoperability, but that patient care decisions not be driven solely on the basis of integrated HIT systems.
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As the PCMH model has not yet been proven to improve health outcomes and coordination of care, specialist reimbursement should not be decreased to pay for PCMH initiatives.
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As PCMH involves the use of health-care professionals such as case managers and pharmacists, who are otherwise not able to bill for and be reimbursed for their professional services, payers need to establish “who” is actually performing the PCMH service so that these professionals can be compensated for their cognitive work.
The AGA believes the PCMH model will work best for patients with three or more chronic conditions, which account for the majority of our nation’s health-care costs. Care coordination can benefit both physicians and patients and can result in more cost-effective and appropriate care. The use of electronic communication, home monitoring and telemedicine, pharmacists and care managers to improve care and optimize health outcomes can be incented through appropriate payment mechanisms. There is an opportunity for physicians and patients to improve care by adopting the principles of coordination, quality, accountability and education.
